Life-threatening Aspiration Research Articles

Interdisciplinary plastic and reconstructive surgery of head and neck squamous cell carcinomas.

Squamous cell carcinomas are the most common malignancies in the oral cavity, pharynx, and larynx. Even in the age of the most modern drug treatment methods, radical resection of these tumors is and currently remains the therapeutic gold standard. The loss of anatomical structures associated with surgery inevitably increases the functional deficits caused by the tumor itself. In this context, the extent of functional deficits is largely determined by the extent of resection. Complete organ resections, such as glossectomy, complete palate resection, laryngectomy, or transverse pharyngo-laryngectomy, lead to severe functional deficits, such as swallowing disturbances with life-threatening aspiration and articulation disorders up to the inability to speak. With the help of plastic reconstructive surgery, the lost tissue can be replaced and the specific functions of the upper aerodigestive tract can be preserved or restored.In recent decades, reconstructive surgical procedures have developed enormously in the treatment of malignant tumors of the head and neck. In order to make optimal use of them, a comprehensive, interdisciplinary therapy concept is a prerequisite for positive oncological and functional outcome. In addition to general medical and social parameters, surgical parameters play a crucial role in the choice of the reconstruction method. The extent to which the surgical measures must be interdisciplinary depends on the localization of the defects in the head and neck region and on the type of replacement tissue required. Here, the expertise of plastic surgery, oral and maxillofacial surgery, and abdominal surgery comes into play in particular. The use of different tissues, the combination of different grafts and flaps, or the preforming of donor regions allow reconstructions far beyond the level of simply restoring surface integrity. The functional results and thus the quality of life of patients after surgical therapy of extensive tumors of the mentioned localizations depend decisively on the type of reconstruction. Therefore, in the following review, special emphasis 1 be placed on the choice of reconstruction method and reconstruction technique for tissue loss after resections of HNSCC.

Comparison of the efficacy and tolerability of different repetitive transcranial magnetic stimulation modalities for post-stroke dysphagia: a systematic review and Bayesian network meta-analysis protocol

IntroductionUp to 78% of patients who had a stroke develop post-stroke dysphagia (PSD), a significant consequence. Life-threatening aspiration pneumonia, starvation, and water and electrolyte abnormalities can result. Several meta-analyses have...

Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study.

Recurrent laryngeal nerve (RLN) palsy is a serious complication of esophagectomy that affects the patient's phonation and the ability to prevent life-threatening aspiration events. The aim of this single-center, retrospective study was to investigate the clinical course of left RLN palsy and to identify the main prognostic factors for recovery. The study cohort consisted of 85 patients who had developed left RLN palsy after minimally invasive McKeown esophagectomy. Vocal cord function was assessed in all participants through laryngoscopic examinations, both in the immediate postoperative period and during follow-up. Permanent palsy was defined as no evidence of recovery after 6months. Univariate and multivariable logistic regression analyses were applied to evaluate the associations between different variables and the outcome of palsy. Twenty-two (25.8%) patients successfully recovered from left RLN palsy. On multivariable logistic regression analysis, active smoking (odds ratio [OR] 0.335, p=0.038) and the use of thoracoscopic surgery (vs. robotic surgery; OR 0.264, p=0.028) were identified as independent unfavorable predictors for recovery from palsy. The estimated rates of recovery derived from a logistic regression model for patients harboring two, one, or no risk factors were 13.16%, 31.15-34.75%, and 61.39%, respectively. Only one-quarter of patients who had developed left RLN palsy after minimally invasive McKeown esophagectomy were able to fully recover. Smoking habits and the surgical approach were identified as key determinants of recovery. Patients harboring adverse prognostic factors are potential candidates for early intervention strategies.

Dysphagia in post Covid-19 Patients- a Prospective Cohort Study.

Never in recent history has mankind been so severely and diversely affected by any disease like the COVID-19 infection. Many post-COVID complications have been mentioned in the literature and other platforms, of which post-COVID Dysphagia is a very distressing complaint. The severity of dysphagia may range from mild discomfort in swallowing to life-threatening aspiration. This paper aims to study post-COVID dysphagia, its various presentations, possible causative factors and diagnosis. Like any other new disease on the block, continuous study and research is the need of the hour, for us to be able to mitigate the damage already inflicted by this pandemic.

Surgical Interventions as a Treatment Option for Severe Dysphagia with Intractable Aspiration: Concept, Indications, and Efficacy

The incidence of dysphagia is increasing, particularly among the elderly according to varied of causes. Patients with severe dysphagia are unable to take food orally and are at risk for life-threatening aspiration pneumonia. Treatments for swallowing disorders focus on restoring oral food intake and preventing recurrent aspiration pneumonia. Therefore, swallowing rehabilitation and food texture modifications are essential. However, in cases with severe or progressive dysphagia, these conservative treatments may not restore oral feeding and prevent intractable aspiration pneumonia. In these cases, surgical interventions has recently been attracted as an alternative treatment option. In this article, we present its concept, indications, and efficacy. Surgeries to restore swallowing function address impaired pharyngolaryngeal motor function during the pharyngeal swallowing stage while preserving laryngeal functions. These procedures include laryngeal elevation, cricopharyngeal myotomy, and vocal cord medialization. Meanwhile, aspiration prevention surgeries reduce the risk of aspiration pneumonia by separating the lower respiratory tract from the pharynx and larynx. These procedures include total laryngectomy, laryngotracheal separation, and glottal closure; although they do not spare laryngeal functions, they prevent aspiration pneumonia completely, improve quality of life, and reduce the burden on caregivers. Clinicians should be aware of surgical interventions as a possible treatment option for intractable dysphagia. Establishment and popularization of the surgical indications are the future issues.

Mediastinoscopy-assisted Transhiatal Esophagectomy (MATHE) in End-stage Achalasia and Gastric Bypass: Technique and Early Results.

Approximately 5% of patients who have undergone prior Heller myotomy and Roux en Y gastric bypass progress to end-stage achalasia (ESA). Surgical options for ESA are often limited to esophagectomy for management of severe dysphagia or life-threatening aspiration episodes. Mediastinoscopy-assisted transhiatal esophagectomy (MATHE) by a small left neck incision combined with an abdominal incision, without using a transthoracic approach, has been reported to reduce pulmonary complications. We herein present the first report of MATHE in 2 consecutive patients with ESA and gastric bypass. Between August 2017 and September 2020, 2 patients who had undergone Heller myotomy and Roux en Y gastric bypass underwent MATHE for ESA. Transhiatal esophagectomy with mediastinoscopy-assisted dissection was performed. The remnant stomach was used as the conduit in both cases. The embedded Supplemental Digital Content 1 (http://links.lww.com/SLE/A269) reports our novel technique. Both cases were completed laparoscopically without conversion to laparotomy or thoracotomy. Median length of hospital stay was 9 days (range, 6 to 11 d). Postoperatively, 1 patient developed a cervical anastomotic leak, which healed with conservative management. No other major complications were observed. MATHE can be safely performed in patients with a history of gastric bypass and ESA without requiring thoracoscopic mobilization of the esophagus. Further studies are required to validate reproducibility of our technique as an alternative to using a thoracic incision.

Stereo Laryngoscopic Impact Site Prediction for Droplet-Based Stimulation of the Laryngeal Adductor Reflex

The laryngeal adductor reflex (LAR) is a vital reflex of the human larynx. LAR malfunctions may cause life-threatening aspiration events. An objective, noninvasive, and reproducible method for LAR assessment is still lacking. Stimulation of the larynx by droplet impact, termed Microdroplet Impulse Testing of the LAR (MIT-LAR), may remedy this situation. However, droplet instability and imprecise stimulus application thus far prevented MIT-LAR from gaining clinical relevance. We present a system comprising two alternative, custom-built stereo laryngoscopes, each offering a distinct set of properties, a droplet applicator module, and image/point cloud processing algorithms to enable a targeted, droplet-based LAR stimulation. Droplet impact site prediction (ISP) is achieved by droplet trajectory identification and spatial target reconstruction. The reconstruction and ISP accuracies were experimentally evaluated. Global spatial reconstruction errors at the glottal area of (0.3±0.3) mm and (0.4±0.3) mm and global ISP errors of (0.9±0.6) mm and (1.3±0.8) mm were found for a rod lens-based and an alternative, fiberoptic laryngoscope, respectively. In the case of the rod lens-based system, 96% of all observed ISP error values are inferior to 2 mm; a value of 80% was found with the fiberoptic assembly. This contribution represents an important step towards introducing a reproducible and objective LAR screening method into the clinical routine.

Laparoscopic fundoplication in infants with life-threatening gastroesophageal reflux disease and associated anomalies as a predictor for surgical intervention

Gastroesophageal reflux disease (GERD) is most commonly seen in infancy. The symptoms abate without treatment in 60% of infants by the age of 6 months while approximately 90% of infants have complete resolution of symptoms by the age of 8–10 months. Infants with severe or life-threatening complications of pathological GERD that is unresponsive to medical therapy can be considered for surgical therapy despite their comorbid illnesses and increased risk for morbidity and mortality. The main type of anti-reflux surgery is fundoplication particularly laparoscopic Nissen fundoplication. Here, we describe a case series of four infants with life-threatening aspiration pneumonia who underwent laparoscopic Nissen fundoplication with gastrostomy button insertion in a single center performed by a single surgeon for complications arising from severe GERD, not responding to medical therapy. Out of four infants, three had complete resolution of symptoms and are thriving well highlighting the vital role played by this novel surgery in treating such infants after failed medical management. However, one infant died of severe morbidity in the post-operative period.

Indications, Surgical Complications, and Long-Term Outcomes in Pediatric Esophageal Reconstructions with Pedicled Jejunal Interposition Graft

Several surgical techniques are available for pediatric esophageal reconstruction. We started to use pedicled jejunum interposition graft (PJIG) because other techniques had significant long-term complications. In this retrospective study, the indications, surgical complications, and long-term outcomes were assessed in patients with PJIG. With ethical consent, we reviewed the hospital records of 14 patients (7 females) who from 2005 to 2019 underwent a total of 16 esophageal reconstructions with PJIG. Median age at PJIG was 1.6 (range: 0.2-15) years. Underlying conditions were esophageal atresia (EA) (n = 11) or native esophagus lost by trauma or infection (n = 3). Eight patients with EA underwent PJIG as primary reconstruction and three as a rescue operation after complications in primary repair. Significant surgical complications occurred in 43% of patients. Major reoperations in six (43%) patients included resection and reanastomosis of strictured proximal PJIG (n = 1) and redo PJIG after failure of the first operation (n = 2). Surgical mortality was nil. After a median follow-up of 6.5 (range: 0.7-14) years, 13 (93%) patients survived, and 1 died of congenital heart disease. PJIG failed in three (23%) survivors of whom two underwent graft removal because of life-threatening aspiration and one did not start oral feeds at all. Ten survivors (77%) have full enteral feeds. Respiratory function in the survivors is satisfactory. Two patients have moderate and three mild gastroesophageal reflux symptoms. PJIG was a functional option for a variety of conditions that required esophageal reconstruction. However, significant early and late complications required major surgical revisions.

PS01.034: GENDER AND BODY MASS INDEX HAVE AN INFLUENCE ON DELAYED GASTRIC EMPTYING FOLLOWING ESOPHAGECTOMY AND GASTRIC PULL-UP

Abstract Background Delayed gastric emptying is a common feature after gastric pull-up for reconstruction following esophagectomy. Symptoms range from mild discomfort to life-threatening recurrent aspiration. Apart from the well-known and technically inevitable truncal vagotomy neither causative factors nor effective preventive measures have been clearly identified. Methods We did a retrospective study in 381 patients (317 males, 64 females; age: 22 -88 years; mean: 62,4 years), who underwent esophagectomy and gastric pull-up with cervical esophagogastrostomy between 1/2008 and 12/2017. During this period the surgical technique had been the same except that in the first phase no intervention at the pylorus had been done (N = 207), whereas in the second pyloromytomy (N = 97) and in the third (N = 110) intrapyloric injection of Botulinum-toxin was performed. Delayed gastric emptying was diagnosed by distension of the conduit with an air-fluid level on chest roentgenogram, and by symptoms and signs of regurgitation or vomiting in absence of other bowel obstruction. 122 patients had retrosternal pull-up due to transmural tumour growth or lymph-nodes, in 259 the orthotopic route was chosen. All patients were followed-up for at least three months after the operation. Results 56 patients (14,7%) developed delayed gastric emptying. Neither pyloromytomy nor injection of Botox had any effect as compared with the patients in the no-intervention period. The route of gastric pull-up had no influence either. In women (N = 15; 23,4%), however, delayed gastric emptying was significantly more frequent than in men (N = 41; 12,9%; P = 0.03). Moreover, the Body Mass Index (BMI) of patients with delayed gastric emptying (BMI = 26.6) was significantly higher than in those who had not (BMI = 24,7; P = 0.03). By multivariate analysis the influence of gender and BMI on the development of delayed gastric emptying remained significant. Conclusion The results of our single center retrospective analysis may show that both, gender and BMI might significantly influence the development of postoperative delayed gastric emptying after esophagectomy and reconstruction by gastric pull-up. For a better understanding and management of delayed gastric emptying prospective trials with larger numbers of patients are definitely needed. Disclosure All authors have declared no conflicts of interest.

Management of the total glossectomy defect with latissimus dorsi free flap

Radical surgical management of tongue cancer results in sever speech and swallowing disruption, impaired airway protection and life-threatening aspiration. Surgical objective of total glossectomy defect management is an adequate restoration of lingual mass and affected tissues of the floor of the mouth. Range of flaps are known to provide the adequate outcome, i. e. pediculed pectoralis major flap, anterolateral free thigh flap, rectus abdominis flap, radial free forearm flap and latissimus dorsi flap. In the current report, we present a case of glossectomy defect reconstruction with pediculed latissimus dorsi flap. Postoperative assessment of the transplant was made according to clinical criteria and viability of the flap was assessed via laser Doppler flowmetry. Signs of microcirculation improved starting from day 5 postoperatively, and were almost equal with donor site microcirculation signs on day 14. A sufficiently large mass of the transplant allowed to create a thickening over the epiglottis, as well as to close the defect in the oral cavity. The latissimus dorsi flap in the tongue reconstruction has a high potential: its use provides a relatively good quality of articulation, recovery of deglutition.

Medialisation thyroplasty with tensor fascia lata: a novel approach for reducing post-thyroplasty complications.

Medialisation thyroplasty is considered the 'gold standard' treatment for unilateral vocal fold paralysis, enabling improvement of voice and swallowing function, and preventing life-threatening aspiration events. The most commonly used laryngeal implants induce some degree of local tissue inflammatory response, and carry the risk of immediate or delayed implant extrusion. This paper describes a novel approach for medialisation thyroplasty. Specifically, it utilises a ribbon of autologous tensor fascia lata harvested at the time of surgery. This is layered within the paraglottic space in a manner similar to Gore-Tex thyroplasty. Thus far, this method has been accomplished in two patients with unilateral vocal fold paralysis, who also received prior radiotherapy to the head and neck. Given the increased risk of post-operative wound breakdown and infection in irradiated patients, it is suggested that this new approach will lead to improved outcomes, and a decrease in complications such as extrusion or wound infection, particularly in this patient population.

Chemical Senses Affecting Cough and Swallowing.

Dysfunction of swallowing and coughing leads to life-threatening aspiration pneumonia, especially in the elderly. In order to induce the cough and swallowing reflexes efficiently, sensory inputs to trigger the reflexes are essential. Both the cough and swallowing reflexes respond to mechanical and chemical stimuli. However, the mechanisms of action of the two reflexes are not homogeneous. Some substances stimulate both reflexes, but others stimulate one of the reflexes and inhibit the other one. Capsaicin, a TRPV1 agonist, stimulates both the cough and swallowing reflexes. Menthol, a TRPM8 agonist, stimulates the swallowing reflex, but it inhibits the cough reflex, especially if applied to the nose. Acid stimulates the cough reflex but its effect on the swallowing reflex is complicated. Theophylline inhibits the cough reflex by decreasing the excitability of sensory nerves, whereas it stimulates the swallowing reflex by antagonizing adenosine receptors. In smoking, cigarette smoke and nicotine have different effects. Cigarette smoke stimulates the cough reflex, while it inhibits the swallowing reflex. Nicotine inhibits the cough reflex but does not affect the swallowing reflex. Whenever you prescribe for an abnormality of one of the reflexes, you should think about the effect of the prescription on the other reflex.

Dysphagia, dystussia, and aspiration pneumonia in elderly people.

Despite the development and wide distribution of guidelines for pneumonia, death from pneumonia is increasing due to population aging. Conventionally, aspiration pneumonia was mainly thought to be one of the infectious diseases. However, we have proven that chronic repeated aspiration of a small amount of sterile material can cause the usual type of aspiration pneumonia in mouse lung. Moreover, chronic repeated aspiration of small amounts induced chronic inflammation in both frail elderly people and mouse lung. These observations suggest the need for a paradigm shift of the treatment for pneumonia in the elderly. Since aspiration pneumonia is fundamentally based on dysphagia, we should shift the therapy for aspiration pneumonia from pathogen-oriented therapy to function-oriented therapy. Function-oriented therapy in aspiration pneumonia means therapy focusing on slowing or reversing the functional decline that occurs as part of the aging process, such as "dementia → dysphagia → dystussia → atussia → silent aspiration". Atussia is ultimate dysfunction of cough physiology, and aspiration with atussia is called silent aspiration, which leads to the development of life-threatening aspiration pneumonia. Research pursuing effective strategies to restore function in the elderly is warranted in order to decrease pneumonia deaths in elderly people.

Invited Commentary

Vocal cord paralysis after thoracic surgery remains an important problem worthy of further study. Vocal cord paralysis markedly impairs quality of life and leads to significant perioperative morbidity [1Schneider B. Bigenzahn W. End A. et al.External vocal fold medialization in patients with recurrent nerve paralysis following cardio-thoracic surgery.Eur J Cardiothorac Surg. 2003; 23: 477-483Crossref PubMed Scopus (38) Google Scholar]. Obviously the best treatment is prevention, which entails a detailed knowledge of the anatomy of the nerve, careful dissection when the nerve is in the field, judicious use electrocautery around the nerve, avoidance of traction injury on the nerve, and a weighing of the risk to benefit ratio when dissecting nodes out from the aortopulmonary window. Surgeons are slow at times to make this diagnosis postoperatively, perhaps because of a wish to avoid a painful discussion and acceptance of a technical problem with the procedure. Indeed prospective reports indicate this complication is underdiagnosed when a comparison is made with retrospective reports [2Filare M. Mom T. Laurent S. et al.Vocal cord dysfunction after left lung resection for cancer.Eur J Cardiothorac Surg. 2001; 20: 705-711Crossref PubMed Scopus (48) Google Scholar]. However, as this report indicates, ignoring this issue puts the patient at risk and is not recommended. Laccourreye and colleagues [3Laccourreye O. Malinvaud D. Delas B. et al.Early unilateral laryngeal paralysis after pulmonary resection with mediastinal dissection for cancer.Ann Thorac Surg. 2010; 90: 1075-1079Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar] reported 69 patients who had early recognition of vocal cord paralysis after lung cancer surgery. All patients had a poor voice quality and two thirds aspirated. Notably, 13% of patients recovered vocal cord function, which rose to 24% if the nerve was not reported to be cut in the operative note. As expected, 90% of the time the left vocal cord was involved due to the greater exposure of the left nerve to surgical injury. Vocal cord medialization was very effective at restoring voice quality and swallowing function. Early involvement of an ear nose and throat (ENT) surgeon and a speech therapist is prudent when confronted with a patient who likely has a vocal cord paralysis after thoracic surgery. Bedside inspection with a nasopharyngoscope can confirm the clinical suspicion of a vocal cord paralysis easily without any anesthesia. Bedside aspiration testing, which is usually followed by a modified barium swallow evaluation conducted by the speech therapist, completes the initial evaluation. Recent reports and my own preference is to have the ENT surgeon inject an absorbable substance in the vocal cord fold to medialize the cord in the early postoperative period. This can be done under local anesthesia at the bedside. The ENT surgeon can then follow the patient in the office to see if vocal cord function returns or not. My ENT surgeon waits at least 6 months (when it is not known if the nerve was irreversibly damaged) before recommending a medialization with a permanent implant, which seems prudent to me. This report indicates that the nerve did not recover function beyond 9 months, but does not elaborate on the pace of recovery of the recovered nerves, which would have been interesting to know. Repeat swallowing evaluation is typically done after any vocal cord intervention and periodically if function remains impaired. Early placement of a percutaneous gastrostomy tube is helpful to facilitate good nutrition in those patients with severe impairment of swallowing function. Most will regain adequate swallowing ability with time and swallowing therapy. Careful management of this sometimes unavoidable complication can prevent life-threatening aspiration and enhance the quality of the patient's life with vocal cord medialization procedures. Early Unilateral Laryngeal Paralysis After Pulmonary Resection With Mediastinal Dissection for CancerThe Annals of Thoracic SurgeryVol. 90Issue 4PreviewThe purpose of this study was to document the symptoms, evolution, management, and outcome in a large series of patients with an early unilateral laryngeal paralysis after mediastinal lymph node dissection and pulmonary resection for cancer. Full-Text PDF

Modulating Effects of Hypoxia and Hypercarbia on Glottic Closing Force

Aspiration has been identified as one of the independent risk factors for development of respiratory tract infections, the incidence of which varies from 10% to 65% in patients in intensive care units. The primary defense mechanism for protection of the lower airway is the glottic closure reflex (GCR), elicited by stimulation of the internal branch of the superior laryngeal nerve. This reflex, once considered highly stable, is now considered vulnerable to a growing number of clinical factors. This study was designed to explore the biomechanical effects of hypoxia and hypercarbia, common occurrences among critically ill patients, on the GCR. Five adult male Yorkshire pigs were used in the study. Both internal superior laryngeal nerves were simultaneously stimulated with bipolar platinum-iridium electrodes. The glottic closing force (GCF) was then measured by placing a pressure transducer between the adducting vocal folds under 3 different protocols: protocol 1 (control), protocol 2 (hypoxia: partial pressure of arterial oxygen [PaO2] levels of 90, 70, and 50 mm Hg), and protocol 3 (hypercarbia: partial pressure of arterial carbon dioxide [PaCO2] levels of 60 and 70 mm Hg). Six readings were recorded under each experimental paradigm, and Student's t-test was applied to calculate the statistical significance against the control. Hypoxia reduced the GCF to 75%, 40%, and 29% of control for PaO2 levels of 90, 70, and 50 mm Hg, respectively, and hypercarbia reduced the GCF to 40% and 27% of control for PaCO2 levels of 60 and 70 mm Hg, respectively. This is the first study that highlights the biomechanical impact of hypoxia and hypercarbia on the GCR, providing a unified explanation for the increased incidence of life-threatening aspiration in critically ill patients with such alterations.

CAN CONTINUING EDUCATION EVER BE HARMFUL?

CAN CONTINUING EDUCATION EVER BE HARMFUL?

Functional reconstruction of near total glossectomy defects using composite gastro omental-dynamic gracilis flaps

The tongue is the most commonly involved structure in cancer of the oral cavity. For locally advanced tumours, adequate resection necessitates near total or total glossectomy. Such patients pose a unique surgical challenge because of the potential for severe speech and swallowing disruption and life-threatening aspiration. These patients also undergo radiotherapy, leading to xerostomia with associated poor quality of life. Present day techniques use dynamic muscles or musculocutaneous flaps for reconstruction of such defects which, although providing adequate glossopalatal contact and tongue movements, are still far from achieving normal tongue appearance and have no intrinsic secretory capability. We have tried to circumvent this problem by using two different free flaps simultaneously, the gracilis muscle to work as functional motor unit for providing tongue movements and elevation together with free stomach, turned inside-out, as an added source of secretion for dry mouth and attached omentum for providing adequate bulk. This technique has been used in two patients over the last 18 months with satisfactory functional and aesthetic results.

Long-Term Results of Laryngeal Suspension and Upper Esophageal Sphincter Myotomy as Treatment for Life-Threatening Aspiration

We evaluated the long-term results of laryngeal suspension and upper esophageal sphincter (UES) myotomy in patients with life-threatening aspiration. In the period 1995 to 2004, 17 patients with severe aspiration caused by insufficient laryngeal elevation and absent or negligible pharyngeal constrictor muscle activity during deglutition resulting in aspiration pneumonia were surgically treated with a laryngeal suspension procedure and UES myotomy. Preoperative and postoperative videofluoroscopy was performed to assess swallowing and aspiration. In 9 of the 17 patients, long-term (more than 1 year) full oral intake without aspiration was achieved. Three other patients demonstrated improvement of deglutition with partial restoration of oral intake with adjusted food consistency, but remained partly dependent on gastrostomy feeding for adequate nutrition. Two patients no longer had cases of aspiration pneumonia, but were unable to achieve even modified oral intake. Three patients finally underwent total laryngectomy--2 of them after initial successful full oral intake without aspiration but with recurrent aspiration as a result of progression of neuromuscular disease. None of the patients succumbed to aspiration pneumonia. In most of our patients, life-threatening aspiration was successfully treated by UES myotomy and laryngeal suspension with restoration of oral intake.

Surgery in the Management of Laryngeal and Hypopharyngeal Carcinoma

Currently, a multitude of treatment options are available for laryngeal and hypopharyngeal carcinoma. Surgery should be considered a viable option in the definitive management of almost all laryngeal and hypopharyngeal tumors, regardless of stage. The characteristics of the primary tumor, as well as the status of the at-risk regional lymph nodes, are critical in the development of a treatment plan. In addition to the patient’s history and physical examination, a comprehensive staging evaluation is required that includes endoscopy, biopsy, and imaging. A patient’s comorbidities and functional status are also important factors to consider during the development of a treatment plan. Surgery as a single modality therapycanbeofferedforearly-stagedisease,andthecombination ofsurgery with adjuvanttherapy(radiotherapywithorwithout chemotherapy) should be used for advanced-stage disease. Surgery also plays a critical role in the management of recurrent or persistent disease, especially after initial nonoperative management. Because survival differences do not exist between surgical and nonsurgical therapies for most clinical scenarios, each patient should undergo a multidisciplinary evaluation to discuss all options before therapy. During the assessment of a laryngeal cancer, the tumor should be classified as either glottic or supraglottic, with isolated subglottic primaries rarely seen. Defining the site of origin, as well as clearly delineating the extent of tumor, is mandatory in developing a surgical plan. Deciding on the surgical options for the primary tumor, as well as whether to address the regional nodal basins, is determined from these tumor characteristics. In general, early glottic tumors are amenable to partial laryngeal resection. Regional metastases are uncommon at presentation and the potential for occult nodal disease is low, making neck dissection usually unnecessary.Moreadvancedglotticprimaries mightstill beamenable to partial laryngeal resection, but total laryngectomy and neck dissection could be required. Supraglottic tumors are also frequently amenable to partial laryngeal resection, but, again, in some instances, total laryngectomy might be required. Most supraglottic tumors, regardless of T stage, require therapy directed to the regional lymph nodes, given the high risk of regional spread. Neck dissection for the regional nodal basin is usually required bilaterally, given the richlymphatics of the supraglottisand the relatively infrequent occurrence of well-lateralized supraglottic primary tumors. Selected laryngeal, as well as hypopharyngeal, carcinomas are best managed by total laryngectomy (with postoperative adjuvant therapy) as the initial treatment. The most common scenario requiring definitive total laryngectomy is a case in which extensive cartilage erosion or extralaryngeal extension of the tumor is present. Patients with these extensive tumors have been shown to have worse disease control when treated by radiotherapy alone compared with surgery and postoperative radiotherapy (1). In the recent multimodality nonoperative organ preservation trials, patients with these extensive T4 tumors were more likely to need salvage laryngectomy or were excluded from participation in the trial (2, 3). The other clinical scenario in which total laryngectomy should be considered is for patients who have life-threatening aspiration at diagnosis. Several surgical organ preservation options exist for laryngeal tumors. These options can beclassified as either openvs. endoscopic procedures. Historically, open laryngeal preservation surgery for glottic tumors included cordectomy or vertical partial laryngectomy and, for supraglottic tumors, included horizontal partial laryngectomy. Near-total laryngectomy has been used for organ preservation in more advanced glottic and supraglottic tumors. Currently, with the success of tracheoesophageal prostheses for speech restoration after total laryngectomy and the success of extended partial laryngeal resection for more advanced tumors, this procedure is rarely performed. More recently, supracricoid laryngectomy and endoscopic laser resection have gained significant popularity in the management of both glottic and supraglottic carcinomas.