Abstract:Objective Oral intake after aspiration prevention surgery (APS) is influenced by postoperative pharyngeal pressure and the dynamics of the upper esophageal sphincter (UES). We examined the effects of less invasive APS combined with UES relaxation techniques (laryngeal closure with cricopharyngeal myotomy [LC-CPM] and central-part laryngectomy [CPL]) on pharyngeal pressure and UES dynamics. Study Design Retrospective, observational study. Setting Single center. Methods We assessed the high-resolution pharyngeal… Show more
“…Sasaki et al modified the glottic closure procedure by adding a layer of laryngeal closure with a sternohyoid muscle flap [ 47 ]. Furthermore, advances in the prevention of postoperative stenosis of the tracheal stoma by combining partial removal of the cricopharyngeal cartilage with glottic closure [ 48 , 49 ] and improvement of the passage of food through the upper esophageal portion by combining bilateral cricopharyngeal myotomy have been reported [ 22 , 50 ]. The advantages of glottic laryngeal closure over total laryngectomy and tracheoesophageal diversion include a higher success rate for aspiration prevention, allowance of swallowing, and less invasiveness [ 49 , 51 ].…”
Section: Surgical Management For Dysphagiamentioning
confidence: 99%
“…They should be performed simultaneously with APS for patients with severe aspiration who require APS and have impaired UES opening or its risk, as aspiration prevention alone cannot sufficiently improve the UES passage of the food bolus (Fig. 2 ) [ 21 , 22 ]. Fig.…”
Background
Severe dysphagia can cause intractable pneumonia and lead to life-threatening conditions. Intractable aspiration can occur despite medical management for aspiration prevention. Surgical intervention is indicated for intractable aspiration to prevent potentially life-threatening complications. Since the 1970s, several surgical treatments to prevent aspiration have been reported, and various aspiration prevention surgeries have been introduced, but little is known about them or their benefits. This is a review of the types of aspiration prevention surgery, with the aim of increasing aspiration prevention surgery awareness and their clinical outcomes among medical professionals, which will guide the choices of aspiration prevention surgeries for patients with intractable aspiration.
Main body
Aspiration prevention surgeries can be categorized into three according to their approaches: removal of the larynx, altering the structure of the trachea, and closure of the larynx. Aspiration prevention surgeries to remove the larynx include total and central-part laryngectomy. Aspiration prevention surgeries to alter the structure of the trachea include tracheoesophageal diversion, laryngotracheal separation, and the tracheal flap method. Surgeries to close the larynx can be divided into supraglottic laryngeal closure, glottic laryngeal closure, and subglottic laryngeal closure. Aspiration prevention surgeries prevent aspiration and increase oral intake in 50–80% of patients. Most patients lose vocal function after aspiration prevention surgeries; however, some patients who have undergone total laryngectomy or laryngotracheal separation restored their speech function through tracheoesophageal puncture and use of voice prosthesis. Postoperative suture failure is frequent after epiglottic flap closure and total laryngectomy but rare after central-part laryngectomy, laryngotracheal separation, glottic closure, and subglottic closure. Furthermore, aspiration prevention surgeries improve the quality of life of patients and their caregivers by decreasing suctioning frequency.
Conclusions
In this review, we described the history and development of aspiration prevention surgeries. Medical professionals need to continually improve their knowledge and skills to facilitate appropriate aspiration prevention surgeries according to patient condition.
“…Sasaki et al modified the glottic closure procedure by adding a layer of laryngeal closure with a sternohyoid muscle flap [ 47 ]. Furthermore, advances in the prevention of postoperative stenosis of the tracheal stoma by combining partial removal of the cricopharyngeal cartilage with glottic closure [ 48 , 49 ] and improvement of the passage of food through the upper esophageal portion by combining bilateral cricopharyngeal myotomy have been reported [ 22 , 50 ]. The advantages of glottic laryngeal closure over total laryngectomy and tracheoesophageal diversion include a higher success rate for aspiration prevention, allowance of swallowing, and less invasiveness [ 49 , 51 ].…”
Section: Surgical Management For Dysphagiamentioning
confidence: 99%
“…They should be performed simultaneously with APS for patients with severe aspiration who require APS and have impaired UES opening or its risk, as aspiration prevention alone cannot sufficiently improve the UES passage of the food bolus (Fig. 2 ) [ 21 , 22 ]. Fig.…”
Background
Severe dysphagia can cause intractable pneumonia and lead to life-threatening conditions. Intractable aspiration can occur despite medical management for aspiration prevention. Surgical intervention is indicated for intractable aspiration to prevent potentially life-threatening complications. Since the 1970s, several surgical treatments to prevent aspiration have been reported, and various aspiration prevention surgeries have been introduced, but little is known about them or their benefits. This is a review of the types of aspiration prevention surgery, with the aim of increasing aspiration prevention surgery awareness and their clinical outcomes among medical professionals, which will guide the choices of aspiration prevention surgeries for patients with intractable aspiration.
Main body
Aspiration prevention surgeries can be categorized into three according to their approaches: removal of the larynx, altering the structure of the trachea, and closure of the larynx. Aspiration prevention surgeries to remove the larynx include total and central-part laryngectomy. Aspiration prevention surgeries to alter the structure of the trachea include tracheoesophageal diversion, laryngotracheal separation, and the tracheal flap method. Surgeries to close the larynx can be divided into supraglottic laryngeal closure, glottic laryngeal closure, and subglottic laryngeal closure. Aspiration prevention surgeries prevent aspiration and increase oral intake in 50–80% of patients. Most patients lose vocal function after aspiration prevention surgeries; however, some patients who have undergone total laryngectomy or laryngotracheal separation restored their speech function through tracheoesophageal puncture and use of voice prosthesis. Postoperative suture failure is frequent after epiglottic flap closure and total laryngectomy but rare after central-part laryngectomy, laryngotracheal separation, glottic closure, and subglottic closure. Furthermore, aspiration prevention surgeries improve the quality of life of patients and their caregivers by decreasing suctioning frequency.
Conclusions
In this review, we described the history and development of aspiration prevention surgeries. Medical professionals need to continually improve their knowledge and skills to facilitate appropriate aspiration prevention surgeries according to patient condition.
“…26) Removing the whole cricoid cartilage in total laryngectomy or CPL facilitates UES relaxation and decreases UES pressure, leading to an influx of air to the esophagus or stomach (aerophagia). 10) Esophageal dysmotility may further contribute to the retention of air in the esophagus. Air retained in the upper gastrointestinal tract should escape to the pharynx to avoid an accumulation of air remaining in the stomach.…”
Section: Discussionmentioning
confidence: 99%
“…Less invasive methods, such as central-part laryngectomy (CPL) or glottic closure, are preferable for patients with severe dysphagia and advanced respiratory impairment. 7,[9][10][11] A CPL removes the middle part of the thyroid cartilage and the entire cricoid cartilage while preserving the lateral aspect of the thyroid cartilage and epiglottis 10) (Fig. 1).…”
Section: Introductionmentioning
confidence: 99%
“…Removing the whole cricoid cartilage leads to decreased upper esophageal sphincter (UES) resting pressure and prolongs the relaxation duration of UES. 10) Given the effects of aspiration-prevention surgeries, patients need to use augmentative and alternative communication (AAC) strategies. Multiple AAC tools are available after the loss of vocal function, including pen and paper, photos/ pictures/symbols/word and alphabet boards, touch-screen devices, mobile applications (apps) on smartphones, and speech-generating devices on a tablet or computer.…”
Background: To prevent aspiration, patients with irreversible dysphagia may undergo surgeries that separate the esophagus and trachea. Such interventions result in loss of vocal function and require alternative communication methods. We report a patient with amyotrophic lateral sclerosis (ALS) who used esophageal speech after receiving a central-part laryngectomy (CPL) to prevent aspiration. Case: A 64-year-old woman with ALS was admitted to our hospital. The patient maintained good cognitive and oral function and presented with mild dysarthria and dysphagia. Faced with rapidly worsening respiratory distress, saliva aspiration, and excessive sputum, she underwent a tracheostomy on the premise of invasive ventilation. Subsequently, the patient began using a voice-generating application for communication. Given the patient's sincere hope to prevent aspiration and aspiration pneumonia, achieve safe oral intake, and decrease caregiver burden for frequent suctioning, the patient underwent a CPL. Following surgery, belching was observed during meals, and the patient could phonate when she belched. This finding led to four speech therapy sessions to practice esophageal speech, allowing the patient to use the pseudo-speech technique for short conversations. Removal of the entire cricoid cartilage in the CPL decreases the upper esophageal sphincter (UES) pressure, thereby allowing air to easily pass through the UES. Therefore, the patient could use the air as a sound source for esophageal speech without extensive training. Discussion: Esophageal speech may be an alternative to oral communication in patients undergoing CPL. Further research is warranted to generalize these findings to patients undergoing CPL.
Objective
In recent years, the use of aspiration prevention surgery (APS) for the treatment of severe dysphagia has been on the rise. However, relevant clinical studies have included small samples, and the frequency of, and risk factors for postoperative complications have not been clarified. We investigated the clinical features of patients undergoing APS and whether oral‐intake status and suction frequency could be reduced.
Study Design
A case series.
Setting
Single‐institution academic center.
Methods
We retrospectively evaluated medical charts generated from 2010 to 2021. The clinical characteristics of patients undergoing APS, changes in the oral‐intake status (Functional Oral Intake Scale, FOIS), suction frequency before and after surgery, risk factors for postoperative complications, and factors contributing to improvements in postoperative oral‐intake status were retrieved.
Results
We included the data of 100 patients (median age: 65 years, 72 men). Amyotrophic lateral sclerosis was the most common primary disease (28%), and glottis closure was the most common APS (69%). Postoperatively, 78% of patients showed improvements in the FOIS score, and suction frequency decreased in 85% of cases. Postoperative complications were observed in 10 patients (10%), wound infection in 6, and bleeding in 4; all improved. Higher preoperative FOIS scores were significantly associated with postoperative complications (p = 0.02).
Conclusion
APS contributed to improving the FOIS score and helped reduce the suction frequency in most cases. APS can be performed safely with proper perioperative management, even in patients with poor preoperative general conditions and nutritional status.
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