Adequate Airway Research Articles

Tracheal autotransplantation after extended hemilaryngectomy for advanced glottic cancer

The surgical treatment of a glottic cancer with fixation of the vocal fold (stage T3) usually consists of a total laryngectomy. Although total laryngectomy may be necessary to ensure adequate tumor margins, this mutilating operation is frequently done because preservation of the healthy laryngeal remnant will not sustain an adequate airway with normal voice production and swallowing. The challenge in the treatment of T3 glottic cancer is to preserve the larynx by reconstruction of the created defect after removal of the tumorally involved hemilarynx. Autotransplantation of the trachea has been shown to succeed in extended laryngeal reconstruction with maintenance of speech, swallowing, and respiration after removal of advanced glottic cancer. These findings will improve laryngeal preservation strategies in treating laryngeal cancer.

MANAGEMENT OF ORBITAL AND OCULAR ADNEXAL TRAUMA

MANAGEMENT OF ORBITAL AND OCULAR ADNEXAL TRAUMA

Mandibular Distraction Osteogenesis in a Neonate

Children with craniofacial anomalies are predisposed to airway obstruction and frequently require airway intervention. Tracheotomy is performed when the airway obstruction is severe and refractory to other less invasive interventions. Tracheotomy is associated with significant morbidity, and there is a trend noted in the literature toward achieving earlier decannulation by the institution of definitive structural changes to the mandible. Mandibular distraction osteogenesis has been shown to alleviate airway obstruction in the pediatric population. We report a case in which mandibular distraction osteogenesis was successfully carried out in a neonate with acute airway obstruction at birth as a result of combined Pierre Robin sequence and Klippel-Feil syndrome. After 1 year, the patient still had an adequate airway with tolerable scarring and no neurologic sequelae.

Pediatric septic shock.

1. Stephen M. Schexnayder, MD* 1. 2. *Associate Professor of Pediatrics & Internal Medicine, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR. After completing this article, readers should be able to: 1. Explain how the host’s immune response may cause toxic effects during sepsis. 2. Delineate the cornerstone of resuscitation in patients who have septic shock. 3. List the factors to be considered when prescribing empiric antimicrobial therapy for septic shock. 4. Explain when referral and transport arrangements should be made for patients in septic shock. Despite major advances in vaccines in the past two decades, septic shock continues to be an important pediatric problem. It is a frequent reason for admission to a pediatric intensive care unit, and this complex problem requires prompt recognition and intervention to improve the likelihood of a good outcome. Because the clinical picture of sepsis is not unique to infectious conditions, a number of definitions have been advocated. Investigators in the field have separated the clinical spectrum of sepsis into the categories of bacteremia, systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, and multiple organ dysfunction syndrome. Clinical observations over the past two decades have led to the description of the systemic inflammatory response syndrome (SIRS) and have identified the major role that endothelium plays in the pathogenesis of this disorder. Infection is one of the major causes of SIRS, but a number of other entities, including trauma, acute respiratory distress syndrome, neoplasms, burns, and pancreatitis, also have been recognized as triggers for this complex series of pathophysiologic events. Although initially written with adult vital sign parameters, the principles behind the definitions shown in Table 1⇓ are valid, and modifications have been proposed for applying them to children. View this table: Table 1. Definitions of the Systemic Inflammatory Response Syndrome Sepsis is a recognized important cause of death, with the highest mortality rate occurring among infants. The most recent data report 5.9 deaths per 100,000 population in infants, with the fatality rate decreasing …

Management of increased intracranial pressure: A review for clinicians

Emergency physicians are frequently confronted with head-injured patients, many of whom have intracranial hypertension. Since direct correlations have been reported between increased intracranial pressure (ICP) and adverse outcome, it is important to rapidly identify and treat these patients. Furthermore, since the actual brain damage that occurs at the time of injury cannot be modified, the maximization of neurological recovery depends upon minimizing secondary insults to the brain, most notably preventing hypotension and hypoxemia. Volume resuscitation to maintain an adequate mean arterial pressure, airway control, and sedation and analgesia to prevent surges in ICP remain the cornerstone of early management. These principles and the emergency department management of the head-injured patient are reviewed in this paper.

Comparison of the Laryngeal Mask Airway and Cuffed Oropharyngeal Airway

In Response: We appreciate the opportunity to reply to Dr. Behringer and would like to comment on each of the points raised. First, we disagree that the results between the single-institute trial [1] and the multicenter trial [2] are in "sharp contrast." In terms of ease of placement, time taken to achieve an adequate airway, first time placement success rates, airway sealing pressure, number of airway interventions required, and postoperative jaw/neck pain, both trials showed that the laryngeal mask airway (LMA) was the superior device. The main contrasting result was that the multicenter trial [2] showed that the cuffed oropharyngeal airway (COPA) had a less frequent incidence of sore throat and the single-center trial [1] showed a less frequent incidence with the LMA. We consider the postoperative data from the single-institute trial more reliable because data collection was double-blinded and the severity was graded, unlike the multicenter trial. Second, we did not make "protestations" that clinical expertise was comparable. We accurately described the experience of the investigators with both devices. Furthermore, in an attempt to measure the performance, we scored the quality of use of each device on a six-point scale using video recordings assessed by an independent investigator. We found that the score was high and similar for both devices, which suggests that both devices were being used according to the manufacturer's recommendations. We apologize for the lack of availability of the "in press" reference, which was accepted for publication by Anaesthesia in September 1997. We made no statement that "the plateau of the COPA's learning curve is reached with as few as 50 insertions." What we found was that there was no evidence of skill acquisition over the first 50 uses when comparing 25-use epochs. We therefore considered that inclusion of investigators with a minimum of 15-use experience [average >40 uses, as chosen in a recent trial [3]] to be reasonable. In the Discussion, we did state, "it is likely that performance of the COPA may improve with increasing individual experience, understanding, and application of the anatomical issues involved." Third, we accept that the use of different drug doses may favor one device or the other, but the optimal regimens are unknown for both devices, although more information is available for the LMA. From a methodological viewpoint, when comparing two devices, it is important to use the same drug regimen; otherwise, the outcome may be drug-related rather than device-related. Two recent studies have compared the response to insertion between the LMA and COPA. Nakata et al. [4] showed that the COPA required a lower minimum alveolar anesthetic concentration of sevoflurane for placement, but Versichelen et al. [3] showed similar hemodynamic and bispectral index changes after induction with propofol. Fourth, we do not consider that the maximal cuff volumes used (50 mL size 10; 60 mL size 11) contributed to the poor performance of the COPA. These volumes were recommended to us by the manufacturer for an earlier study and have since been revised. In our experience, higher volumes do not provide a better seal and are associated with unacceptably high in vivo intracuff pressures. Finally, we agree that the COPA deserves more careful scrutiny to fully define its appropriate clinical usage. However, a finding common to all published reports is that the COPA is not a consistently hands-free device. J. R. Brimacombe, MB ChB, FRCA, MD J. C. Brimacombe, BSc Department of Anaesthesia and Intensive Care; Cairns Base Hospital; Cairns, Australia A. M. Berry, MB ChB, FRCA Department of Anaesthesia and Intensive Care; Nambour General Hospital; Nambour, Australia

Comparison of the Laryngeal Mask Airway and Cuffed Oropharyngeal Airway

In Response: We appreciate the opportunity to reply to Dr. Behringer and would like to comment on each of the points raised. First, we disagree that the results between the single-institute trial [1] and the multicenter trial [2] are in "sharp contrast." In terms of ease of placement, time taken to achieve an adequate airway, first time placement success rates, airway sealing pressure, number of airway interventions required, and postoperative jaw/neck pain, both trials showed that the laryngeal mask airway (LMA) was the superior device. The main contrasting result was that the multicenter trial [2] showed that the cuffed oropharyngeal airway (COPA) had a less frequent incidence of sore throat and the single-center trial [1] showed a less frequent incidence with the LMA. We consider the postoperative data from the single-institute trial more reliable because data collection was double-blinded and the severity was graded, unlike the multicenter trial. Second, we did not make "protestations" that clinical expertise was comparable. We accurately described the experience of the investigators with both devices. Furthermore, in an attempt to measure the performance, we scored the quality of use of each device on a six-point scale using video recordings assessed by an independent investigator. We found that the score was high and similar for both devices, which suggests that both devices were being used according to the manufacturer's recommendations. We apologize for the lack of availability of the "in press" reference, which was accepted for publication by Anaesthesia in September 1997. We made no statement that "the plateau of the COPA's learning curve is reached with as few as 50 insertions." What we found was that there was no evidence of skill acquisition over the first 50 uses when comparing 25-use epochs. We therefore considered that inclusion of investigators with a minimum of 15-use experience [average >40 uses, as chosen in a recent trial [3]] to be reasonable. In the Discussion, we did state, "it is likely that performance of the COPA may improve with increasing individual experience, understanding, and application of the anatomical issues involved." Third, we accept that the use of different drug doses may favor one device or the other, but the optimal regimens are unknown for both devices, although more information is available for the LMA. From a methodological viewpoint, when comparing two devices, it is important to use the same drug regimen; otherwise, the outcome may be drug-related rather than device-related. Two recent studies have compared the response to insertion between the LMA and COPA. Nakata et al. [4] showed that the COPA required a lower minimum alveolar anesthetic concentration of sevoflurane for placement, but Versichelen et al. [3] showed similar hemodynamic and bispectral index changes after induction with propofol. Fourth, we do not consider that the maximal cuff volumes used (50 mL size 10; 60 mL size 11) contributed to the poor performance of the COPA. These volumes were recommended to us by the manufacturer for an earlier study and have since been revised. In our experience, higher volumes do not provide a better seal and are associated with unacceptably high in vivo intracuff pressures. Finally, we agree that the COPA deserves more careful scrutiny to fully define its appropriate clinical usage. However, a finding common to all published reports is that the COPA is not a consistently hands-free device. J. R. Brimacombe, MB ChB, FRCA, MD J. C. Brimacombe, BSc Department of Anaesthesia and Intensive Care; Cairns Base Hospital; Cairns, Australia A. M. Berry, MB ChB, FRCA Department of Anaesthesia and Intensive Care; Nambour General Hospital; Nambour, Australia

The Cuffed Oropharyngeal Airway and Management of the Difficult Airway

Assistant Professor of Anesthesiology (Uezono)Assistant Professor of Anesthesiology (Goto)Professor of Anesthesiology and Chair; Department of Anesthesiology; Teikyo University Ichihara Hospital; 3426-3 Anesaki Ichihara Chiba 299-0111, Japan (Morita)In Reply:-We thank Patel et al. [1]for their interest in our article describing the use of the cuffed oropharyngeal airway (COPA) in the management of the difficult airway and nasal fiberscopic intubation.We agree that the COPA does not always provide hands-free airway support as shown in the recent article. [2]However, the manual support required when using the COPA is not as extensive as with the endoscopic mask. For example, the first patient in our report [1]required only a gentle chin lift with one finger. More importantly, as shown in our second case, [1]the need for additional airway support can often be eliminated with the proper use of the white rubber strap (commercially supplied with the COPA) or a slight neck rotation to a side, or both.The study Dr. Patel cited as an evidence for the relative ineffectiveness of the COPA compared to the endoscopic mask in supporting ventilation [3]is not applicable because the authors used muscle relaxants and compared the COPA with a face mask while using positive ventilation. However the COPA, similar to the laryngeal mask airway, is designed predominantly for use during spontaneous respiration and NOT for paralyzed patients. Muscle relaxation, by reducing the tone of the upper airway muscles, presumably renders the pharyngeal seal by the COPA less effective.We admit that the nasal tracheal intubation with the COPA in place requires somewhat complicated manipulations, as described in the letter, probably because the fiberscope passes around the lateral side of the cuff of the COPA. However, we found these technical difficulties relatively easy to overcome, as evidenced by the steep learning curve in our study. [1]Moreover, we had very positive feedback from both resident and staff anesthesiologists. Residents may perform fiberoptic intubation at their own pace while the patient is asleep. For staff, maintaining an adequate airway and an optimal depth of anesthesia provided by the COPA enhances patient safety while teaching fiberoptic intubation. Therefore, we believe our technique facilitates the teaching and learning of fiberoptic intubation.In conclusion, our case report suggests that (1) in cases in which difficult intubation is anticipated, the COPA permits spontaneous breathing and inhalation anesthesia while nasal fiberoptic intubation is being performed and (2) the presence of the COPA does not interfere with the passage of the fiberscope.Shoichi Uezono, M.D.Assistant Professor of AnesthesiologyTakahisa Goto, M.D.Assistant Professor of AnesthesiologyShigeho Morita, M.D.Professor of Anesthesiology and Chair; Department of Anesthesiology; Teikyo University Ichihara Hospital; 3426-3 Anesaki Ichihara Chiba 299-0111, Japan(Accepted for publication November 17, 1998.)

Phonosurgery techniques after partial laryngectomy

Voice quality considerations in patients undergoing partial laryngectomy are secondary to oncological surgery. The need for adequate airway and swallow also precedes voice considerations. However, after the cancer has been cured, dysphonia becomes a major impact on the quality of life. This prompts many patients to seek further treatment for improving voice after partial laryngectomy. The laryngectomy defect is variable and may result in defects of hard or soft tissue. This study will describe four operative techniques to rehabilitate the voice after partial laryngectomy. The techniques used are those from phonosurgery and include buccal mucosal graft implantation and resurfacing, lipoinjection, laryngeal skeleton reconstruction, and thyroplasty with medialization laryngoplasty. Successful phonosurgical rehabilitation should consider the needs of the patient, a complete analysis of the preoperative defect during phonation, and analysis of the defect with computer tomographic scan evaluation of the larynx.

Management of pediatric laryngeal papillomatosis

It is disheartening to make the diagnosis of recurrent respiratory papillomatosis in a young child. This disease presents in the infant or young toddler with symptoms of worsening hoarseness, stridor, and sometimes respiratory distress. Such children will undergo multiple procedures in their lifetimes to clear their airways of papillomas; it is not uncommon to see a child return as many as 60 to 100 times. Otolaryngologists have successfully developed equipment and techniques to maintain an adequate airway in almost all cases of laryngeal papilloma. Unfortunately, achieving a satisfactory voice outcome both in the short term as well as in the long run is a much more difficult problem.

On-Field Examination and Care

The on-site physician at an athletic event must be able to recognize life-threatening conditions, provide initial care for all conditions, and direct transport if needed. Preparation is critical for avoiding catastrophe; it involves establishing communication and protocol beforehand, as well as developing a mental checklist for assessing injuries. After ensuring an adequate airway, breathing, and circulation, the examiner determines the patient's level of consciousness, mental status, and symptoms and assesses for neck injury. The physician may then need to prepare for emergency transport or for further evaluation on the sidelines.

Endo-extralaryngeal suture technique for endoscopic lateralization of paralyzed vocal cords

The development of the Lichtenberger endo-extralaryngeal needle carrier has allowed suture lateralization of the vocal cord in 54 patients with bilateral abductor vocal cord paralysis. Of the 54 patients, 53 are included in the results, and in 50 patients this was the one and only operation necessary for improvement of their airway. Forty-eight patients underwent a tracheotomy, but underwent decannulation after the procedure. Five patients did not require a tracheotomy. Three patients' cases were considered failures because they required a second open operation to successful decannulate. Two basic methods of vocal cord lateralization are described. In 10 cases the procedure(s) was performed bilaterally to create an adequate airway. Voice quality remained excellent in 35 of the 53 patients. The remaining 18 patients had adequate airways but less than adequate voice.

Type II isshiki thyroplasty in the management of dyspnea in bilateral vocal cord paralysis or immobility

Bilateral vocal cord paralysis remains a serious and sometimes life-threatening problem. Management of the glottic airway is complicated by the necessary trade between voice and adequate breathing. This article outlines specific instances in which airway may be improved with very little harm to the voice. Three adult females presented between January 1993 and September 1995 with dyspnea secondary to thyroidectomy-induced bilateral vocal cord paralysis. Increasing dyspnea on exertion prompted their clinic examinations, and videostroboscopy revealed glottal obstruction secondary to bilateral cord paralysis and vocal fold mucosal laxity, the Bernoulli effect causing increased inspiratory obstruction. All three women opted for a unilateral Type II Isshiki thyroplasty instead of long-term tracheotomy tube placement or other management options. The surgical goal was to tighten the lax mucosa on the most involved side and slightly lateralize the vocal cord, hopefully resulting in both adequate airway and better postoperative voice. Surgery was accomplished under attended local anesthesia with tracheotomy tube placement for airway control. Two patients were successfully decannulated within 6 weeks postoperatively with marked improvement in breathing and a higher-pitched, near-normal voice as gauged by videostroboscopy and voice analysis. The other patient required an emergency tracheotomy preoperatively and has elected to keep her tracheotomy tube in place and corked during the day, unplugging it at night and for strenuous exercise. Long-term follow-up confirms the stability of the initial results, and the Type II thyroplasty is offered as yet another tool in the management of dyspnea in females with bilateral vocal cord paralysis.

Pediatric laryngotracheal reconstruction

The management of pediatric laryngotracheal stenosis is a difficult problem and often involves multiple surgical procedures. The goals of laryngotracheal reconstructions are to create an adequate airway, a serviceable voice, and a competent larynx. In this article, the etiology, diagnosis, and surgical management of pediatric laryngotracheal stenosis are discussed.

Right Upper Lobe Sleeve Resection

The first plastic-reconstructive procedures of the airway were performed after traumatic injury and tuberculous bronchostenosis.' The success of these early procedures led to the first bronchial sleeve resection for adenoma2 and c a r c i n ~ m a , ~ ? ~ during 1951 through 1952. Sleeve lobectomy was considered an alternative to pneumonectomy in patients with bronchogenic carcinoma because it preserved lung tissue and improved the quality of postoperative survival. Recent long-term studies of patients with lung carcinoma suggest that the results of sleeve lobectomy are comparable to the expected survival after standard lobectomy or pneumonectomy. Weisel et a15 reported no difference in the actuarial survival of 70 patients undergoing sleeve lobectomy compared with 70 patients undergoing pneumonectomy for stage I or I1 disease. Firmin et a16 showed that sleeve resection of squamous cell carcinoma of the upper lobe, in the absence of nodal metastases, produced a 5-year survival of 71%. In a series of 52 patients with T2NO or T3NO squamous cell carcinoma, sleeve lobectomy produced 5and 10-year survival rates of 59% and 47%.7 In a series of 101 sleeve lobectomies for stage I through stage I11 disease, RushPresbyterian-St. Luke's Medical Center reported overall 5-year survival rates of 30% to 33%.839 The right upper lobectomy is the most common sleeve resection. Surveys in Japan have shown that upper-lobe sleeve resections represent 87% of all sleeve lobectomies performed.I0 Because of the relative length of the bronchus intermedius and the favorable arterial anatomy, right upper-sleeve lobectomies are performed more than twice as frequently as left upper-sleeve lobectomies. lo A review of several published patient series support these findings with 76% of the sleeve lobectomies being performed for cancers of the right upper l 0 b e . ~ 1 ~ J ~ J ~

Effect of the TI/TE ratio on mean intratracheal pressure in high-frequency oscillatory ventilation.

In high-frequency oscillatory ventilation (HFOV), an adequate mean airway pressure is crucial for successful ventilation and optimal gas exchange, but air trapping cannot be detected by the usual measurement at the y piece. Intratracheal pressures produced by the high-frequency oscillators HFV-Infantstar (IS), Babylog 8000 (BL), and the SensorMedics 3100A (SM) [the latter with either 30% (SM30) or 50% (SM50) inspiratory time] were investigated in four anesthetized tracheotomized female piglets that were 1 day old and weighed 1.6-1.9 kg (mean 1.76 kg). The endotracheal tube was repeatedly clamped while the piglets were ventilated with an oscillation frequency of 10 Hz, and the airway pressure distal of the clamp was recorded as a measure of average intrapulmonary pressure during oscillation. Clamping resulted in a significant decrease of mean airway pressure when the piglets were ventilated with SM30 (-0.86 cmH2O), BL (-0.66 cmH2O), and IS (-0.71 cmH2O), but airway pressure increased by a mean of 0.76 cmH2O with SM50. Intratracheal pressure, when measured by a catheter pressure transducer at various oscillation frequencies, was lower than at the y piece by 0.4-0.9 cmH2O (SM30), 0.3-3 cmH2O (BL), and 1-4.7 cmH2O (IS) but was 0.4-0.7 cmH2O higher with SM50. We conclude that the inspiratory-to-expiratory time (TI/TE) ratio influences the intratracheal and intrapulmonary pressures in HFOV and may sustain a mean pressure gradient between the y piece and the trachea. A TI/TE ratio < 1:1 may be useful to avoid air trapping when HFOV is used.

Cerebral perfusion pressure during percutaneous dilatational tracheostomy

Objective: To assess the impact of the Ciaglia percutaneous dilatational tracheostomy (PDT) on intracranial pressure (ICP) in patients with severe brain injury. Design: Prospective observational study. Setting: Neurosurgical intensive care unit (nICU) of a university hospital. Subjects: Fifteen patients admitted to our nICU with severe brain injury, for whom PDT was scheduled provided that: i) prolonged nasotracheal intubation was anticipated because of the lack of adequate spontaneous ventilation and/or airway protection; ii) no haemostatic defect was apparent; iii) no lesions of the neck (traumatic, neoplastic, infectious, etc) were present; iv) extension of the neck was possible and did not cause ICP elevation; v) ICP was monitored via an intraparenchymal Camino device. Over the previous 24 hours cerebral perfusion pressure (CPP) was always ≥70 mm Hg, ICP ≤20 mm Hg and cerebrospinal fluid was not drained. Interventions: Ciaglia percutaneous dilatational tracheostomy. Measurements and main results: CPP...

Emergency management of pediatric burn victims.

Pediatric burn injuries present a major challenge to the health care team, but an orderly, systematic approach can simplify the initial stabilization and management. A clear understanding of the pathology of burn injuries is essential in providing quality burn care in the prehospital setting and at the referring hospital. After the patient has been rescued from the offending agent, assessment of the burn victim begins with the primary survey and life-threatening injuries initially addressed first. This is followed by a secondary survey to document and treat other injuries or problems. Intravenous access may be established in concert with the local/regional medical control and appropriate fluid resuscitation begun. Burn wounds should be covered with clean, dry sheets, and the patient kept warm with blankets to prevent hypothermia. The patient should be transported to the local hospital ED in the most appropriate mode available. At the local hospital, it should be determined if the burn patient needs burn center care, using the ABA Guidelines. In preparing for and organizing the transfer of the burn victim, consideration must be given to the continued monitoring and management of the patient during transport. In transferring burn patients the same priorities developed for the prehospital management are still operative. During the initial assessment and treatment and throughout the transport, an adequate airway, breathing, circulation, fluid resuscitation, urine output, and pain control must be assured. Ideally, transport of burn victims will occur through and organized, protocol driven plan that includes specialized transport mechanisms and personnel. Successful transport of burn victims, whether in the pre-hospital phase or during inter-hospital transfer, requires careful attention to treatment priorities, protocols, and attention to detail.

気道反射における喉頭の機能, 調節機構

The glottis closes during not only cough reflex but also sneezing. It indicates that the activity of laryngeal motor neurons within the nucleus ambiguus is influenced by both the superior laryngeal and the trigeminal afferents. In this study, the convergence of inputs originated from the superior laryngeal and the anterior ethmoidal nerves is examined in decerebrate cats. Thirty two neurons are activated orthodromically by ipsilateral stimulation to the superior laryngeal nerve. Fifty eight neurons are activated orthodromically by ipsilateral stimulation to the anterior ethmoidal nerve. These two neuronal groups are overlapped each other in the nucleus reticularis parvicellularis of medulla. However, the neurons receiving afferents from the superior laryngeal nerve tend to exist in the dorso-lateral portion of the nucleus, while the neurons receiving afferents from the ethmoidal nerve tend to exist in the medio-ventral portion. Seven neurons receive afferents from both nerves. Most of these neurons are located in the overlapped area of two neuronal groups, which is apart from the nucleus ambiguus. The projectional pattern that different inputs converge into the reticular neurons outside of the nucleus ambiguus can be useful for evoking the adequate airway reflex related to the larynx.

Treatment of chronic aspiration secondary to laryngeal stent by endoscopic capping.

Maintaining an adequate airway after laryngotracheal reconstruction (LTR) is an important factor in achieving a successful outcome. Intraluminal stenting has long been advocated. The purposes of an intraluminal stent are to hold grafts or flaps in position, to support the reconstructed but still unstable laryngotracheal framework, and to prevent scar contracture. A polytef (Teflon) stent is commonly used after LTR in the pediatric age group. 2 This hollow stent, introduced initially by Aboulker et al, 3 seems to induce less tissue reaction, while allowing voice and respiration. The hole also aids in easy endoscopic removal of the stent. Usually, the top of the stent must be positioned above the level of the false vocal cords, thus exposing the patient to possible aspiration. In a small number of patients, aspiration may persist, causing significant morbidity. We describe an endoscopic procedure to eliminate postoperative aspiration that fails to resolve with time, by endoscopic capping of the hollow laryngeal stent.