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Phys Med Rehabil Clin N Am
19 (2008) 817–835
Surgical Treatment of Dysphagia
Liat Shama, MD, Nadine P. Connor, PhD,
Michelle R. Ciucci, PhD,
Timothy M. McCulloch, MD*
Division of Otolaryngology-Head & Neck Surgery, Department of Surgery,
University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue,
Madison, WI 53792-7373, USA
Dysphagia encompasses a wide range of etiologies. Its proper evaluation
and treatment uses tools and expertise from a variety of specialties working
toward the common goals of safety and satisfactory quality of life. Most
causes of dysphagia do not require surgical intervention to accomplish these
goals; however, several entities warrant surgery to treat a specific problem or
to augment medical/therapeutic management. As medicine has made amazing technological and pharmacologic advances, it also has sought a more
holistic approach to patients, including quality of life as an integral part
of care. Certain surgical therapies for dysphagia address this perspective.
The head and neck surgeon can be an important member of the dysphagia rehabilitation team. This role maybe underemphasized in the current era
of percutaneous gastrostomy tubes and accelerated medical care. The role of
surgery is well defined for some causes of dysphagia and is less well defined
for others. For example, the management of glottic insufficiency, Zenker’s
diverticulum, cricopharyngeal dysfunction, pharyngoesophageal stricture,
and sialorrhea, as related to dysphagia, routinely includes surgery (Table 1).
In contrast, the role of surgery for dysphagia in patients who have progressive neuromuscular disease, stroke, or polyneuropathy is less well defined
and controversial. This article includes a general overview of the causes of
dysphagia that can be addressed successfully with surgery as well as a discussion of why surgery may be less appropriate for other conditions associated
with dysphagia.
* Corresponding author.
E-mail address: mccull@surgery.wisc.edu (T.M. McCulloch).
1047-9651/08/$ – see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.pmr.2008.05.009
pmr.theclinics.com
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Table 1
Surgical intervention for dysphagia
Indication
Intervention
Cricopharyngeal dysfunction
Botox injection
Cricopharyngeal myotomy
Cricopharyngeal myotomy with diverticulum resection,
endoscopic or external approach
Temporary: injection laryngoplasty
Permanent: repeated injection laryngoplasty, medialization
thyroplasty with or without arytenoid adduction
Laryngotracheal separation
Total laryngectomy
Relocation of salivary ducts
Excision of submandibular salivary glands
Zenker’s diverticulum
Glottic insufficiency
Intractable aspiration
Sialorrhea
Cricopharyngeal dysfunction
The cricopharyngeus muscle is situated at the junction of the hypopharynx and the esophagus and is integral to the complex swallowing action.
This muscle maintains a static contraction with momentary relaxation during the pharyngeal swallow to allow passage of the bolus into the esophagus.
The cricopharyngeus muscle then contracts actively, initiating the primary
peristaltic wave of the esophagus [1]. Accordingly, temporal parameters of
muscle relaxation and contraction are critical to the initiation of the esophageal phase of the swallow.
Nearly all cases of cricopharyngeal dysfunction produce signs and symptoms of dysphagia, including reported choking or difficulty swallowing, multiple attempts at swallowing a bolus, nasopharyngeal reflux, globus,
aspiration, and regurgitation. Cricopharyngeal dysfunction generally manifests as a cricopharyngeal bar (Fig. 1A, B), cricopharyngeal spasm, or a sluggish, incoordinated cricopharyngeus muscle visualized on lateral-view
barium-contrast video swallow studies [2,3]. The mechanisms of dysfunction
include isolated or esophageal reflux-induced spasm and hypertonicity;
neuropathy with poor coordination, muscular contractions, and incomplete
cricopharyngeus muscle relaxation; muscular stiffening secondary to inflammation from internal (myositis) and external (radiation) sources; and combined causes as seen with aging [4]. Disorders such as myasthenia gravis,
muscular dystrophy, and stroke may be associated with incoordination of
the pharyngeal constrictors and the cricopharyngeal muscle, which may
lead to dysphagia [1]. Other conditions that may cause cricopharyngeal dysfunction resulting in dysphagia include amyotrophic lateral sclerosis, multiple sclerosis, and injuries to the vagus nerve, pharyngeal nerve plexus, and
recurrent laryngeal or superior laryngeal nerves [5,6]. Additionally, cricopharyngeal opening is related to hyolaryngeal elevation and forward traction as well to pharyngeal bolus-propulsive forces; therefore any weakness
SURGICAL TREATMENT OF DYSPHAGIA
819
Fig. 1. The cricopharyngeal bar and the endoscopic surgical approach. (A) Lateral videofluorographic view of the cricopharyngeal bar. (B) Endoscopic view of cricopharyngeal bar. (C)
Endoscopic view of completed carbon dioxide laser myotomy.
of the lingual or pharyngeal muscle can decrease cricopharyngeal opening,
resulting in abnormally high hypopharyngeal pressures during swallowing.
Cricopharyngeal dysfunction should be considered in any patient who
presents with dysphagia [1]. Factors indicating potential cricopharyngeal
dysfunction include diet modification, weight loss, globus sensation, aspiration, cough, and regurgitation [2]. Patients who have symptomatic cricopharyngeal dysfunction should be referred to the dysphagia team for
assessment and management to prevent malnutrition, dehydration, and
aspiration pneumonia [3]. Therapeutic modalities for cricopharyngeal
dysfunction include mechanical dilatation and chemical denervation with
botulinum toxin injections as well as surgical weakening with cricopharyngeal myotomy.
Management of cricopharyngeal dysfunction: botulinum toxin injection
Botulinum toxin injection of the cricopharyngeus muscle leads to relaxation of the upper esophageal sphincter. It is useful for cricopharyngeal achalasia and spasm. It often is done under general anesthesia for direct
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visualization of the cricopharyngeus muscle to ensure accurate drug placement, but it can be done in an awake patient in the office aided by electromyography [7–11]. The effect of botulinum toxin is temporary, and repeat
injections may be required. Because botulinum toxin may spread to adjacent
tissues, the accuracy of the injection and the use of the lowest effective dose
are essential for success. Inadvertent diffusion to the adjacent muscles of the
larynx can lead to voice and airway problems.
Botulinum toxin injection for cricopharyngeal muscle dysfunction has
been shown to improve swallowing ability in approximately 75% of patients
[9]. Improvement was assessed via patient report and by objective measures
of esophageal manometry, videofluoroscopy, and laryngeal electromyography. In patients who did not have a positive response to botulinum toxin
injection, cricopharyngeal myotomy was shown to improve dysphagia
70% of the time [12].
Management of cricopharyngeal dysfunction: cricopharyngeal myotomy
Cricopharyngeal myotomy is a surgical procedure that involves cutting
the cricopharyngeus muscle, using either an external or an endoscopic approach. The endoscopic approach may be performed with the use of a laser
such as a carbon dioxide or neodymium-doped yttrium aluminum garnet
laser. The former is favored because it has less collateral thermal tissue
interaction (Fig. 1C) [4,13]. Myotomy has the advantage of affecting both
the muscular and connective tissue components of the cricopharyngeus.
It can be effective in the treatment of inflammatory and fibrotic disorders
where botulinum toxin may fail. It is the recommended surgical treatment
for hypertonicity of the cricopharyngeus muscle as determined by esophageal manometry and is part of the surgical therapy for Zenker’s diverticula
[2]. Cricopharyngeal myotomy generally is indicated if patients have moderate to severe dysphagia and sequelae such as weight loss and pneumonia, if
there are obvious physical findings on radiographic studies, and if the
patient can tolerate surgery [4]. Cricopharyngeal myotomy has been shown
to normalize the upper esophageal sphincter relaxation pattern, allowing
a more normal swallow and thereby decreasing dysphagia [2]. Generally,
the endoscopic approach is preferred because it is shorter in duration and
is less invasive than the external approach. The endoscopic approach has
fewer associated risks but may have a slightly higher a risk of mediastinitis
and is not possible in all patients because of the limitations of rigid endoscopy [4]. Possible complications of the external approach include hemorrhage, hematoma, damage to the recurrent laryngeal nerve, wound
infection, and pharyngocutaneous fistula.
The role and timing of surgery for patients who have mild or intermittent
symptoms and less obvious cricopharyngeal pathology on swallowing studies is controversial. These patients maybe taught swallowing strategies such
as the Mendelsohn maneuver (ie, lifting or elevating the larynx with the
SURGICAL TREATMENT OF DYSPHAGIA
821
muscles of the neck for a few seconds during the swallow to encourage the
upper esophageal sphincter to open) or effortful swallowing (ie, bearing
down or ‘‘squeezing’’ the neck muscles during the swallow) with the goal
of compensating for the poor cricopharyngeus function. The addition of
simple procedures such as transoral myotomy, cricopharyngeal dilatation,
and/or botulinum toxin injections could augment the swallowing therapy
and, in many cases, could guarantee its success.
Zenker’s diverticulum
Zenker’s diverticulum (Fig. 2) is within the spectrum of cricopharyngeal
dysfunction. Although the pathophysiology of the diverticulum is not completely clear, it is apparent that incomplete or poorly timed cricopharyngeal
relaxation plays a central role in its development and expansion. It is suggested that intrapharyngeal pressure with inadequate relaxation of the cricopharyngeus muscle leads to fibrosis of the muscle fibers over the area of
increased pressure [14]. Surgical treatment for Zenker’s diverticulum should
be considered in patients who are symptomatic, because the sequelae may be
life threatening: patients may have significant weight loss and be at risk of
aspiration of the diverticulum contents. Additionally, dietary limitations
may require lifestyle modifications and alter the patient’s quality of life,
Fig. 2. Lateral videofluorographic view of a Zenker’s diverticulum.
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which may be improved with surgical treatment. If patients are asymptomatic, or if the diverticulum causes minimal symptoms, long-term monitoring
may be considered in lieu of immediate surgical management.
Most of these patients have intact hypopharyngeal contraction forces,
and in most cases the surgical intervention of cricopharyngeal myotomy,
with or without removal of the diverticulum pouch, alleviates symptoms.
Most patients who have Zenker’s diverticulum have a relatively obvious
problem with severe symptoms. Because the surgery is simple and has
a high probability of a positive outcome, the choice to proceed is straightforward. The trend in the United States has been toward using transoral
approaches and to complete the myotomies with either laser techniques or
endoscopic stapling. The outcomes are equally good with either approach,
and the risks are the same, so either approach is justified [15]. Open cricopharyngeal myotomy now is used primarily when neck anatomy and/or
cervical spine stiffness prevent the placement of a necessary pharyngoscope.
The external approach to resection of a Zenker’s diverticulum involves
a cervical neck incision with dissection to identify the diverticulum, which
then is freed from the surrounding tissues. A cricopharyngeal myotomy is
performed next, followed by excision, inversion, or suspension of the pouch
using a suture or staple technique [4]. This approach has a higher rate of
complications, including fistulas, recurrent laryngeal nerve palsy, pneumomediastinum, and mediastinitis, and has been passed over for newer, safer
endoscopic techniques. Compared with open surgery, endoscopic methods
lead to a shorter postoperative course with very low rates of serious complications such as mediastinitis [15,16]. Additionally, most patients report relief
of symptoms after endoscopic surgery [13]. Endoscopic techniques include
an endoscopic staple diverticulostomy and a laser-assisted technique. This
technique uses a modified bivalved laryngoscope to visualize the diverticulum. Division of the common wall between the diverticulum and the esophagus is performed with electrocautery, carbon dioxide laser, or staples,
thereby performing an internal cricopharyngeal myotomy and creating a single lumen [13]. Some controversy remains as to which endoscopic approach
is best. Each has merits and limitations, but the published data show little or
no significant difference in outcomes and risk (Table 2).
Glottic insufficiency
The larynx contains the glottis, which is the space between the true vocal
folds and which has three primary functions: airway protection, respiration,
and phonation [17–20]. Glottal insufficiency is defined as the inability of the
vocal folds to adduct fully and thus protect the lower airway during swallowing or voice production (Fig. 3A).
The laryngopharyngeal events that allow a safe swallow are highly
orchestrated. Sphincterlike glottic closure occurs for only a brief time at the
point of bolus transfer from the pharynx to the esophagus [21]. Although
823
SURGICAL TREATMENT OF DYSPHAGIA
Table 2
Risks and outcomes of cricopharyngeal myotomy for Zenker’s diverticulum
Type of
cricopharyngeal
myotomy
Advantages
External
approach
Access to large
diverticula
Endoscopic
Least operative
staple-assisted
time
Fastest return
to oral diet
Shortest hospital stay
Endoscopic
laser-assisted
Intermediate return
to oral diet
Endoscopic
cautery
Longest operative
time
Longest return
to oral diet
Risks and
disadvantages
Fistula, recurrent
laryngeal
nerve palsy,
mediastinitis
Esophageal
perforation,
pneumomediastinum
Cannot always
be placed
through scope or
used for smaller
diverticula
Produces an
incomplete
myotomy at the tip
Thermal tissue injury
Outcomes
Effective, with a
higher complication
rate than endoscopic
approaches
2.6% complication
rate
0.3% mortality
rate
6% recurrence rate
3%–8.1%
complication rate
0.2% mortality rate
Postoperative fever,
3 to 11.5%
pneumomediastinum,
recurrence rate
hemorrhage
Thermal tissue injury,
7.4% complication
fistula, mediastinitis,
rate
hemorrhage
0% mortality rate
3.4% recurrence rate
From: Chang CY, Payyapilli RJ, Scher RL. Endoscopic staple diverticulostomy for Zenker’s
diverticulum: review of literature and experience in 159 consecutive cases. Laryngoscope
2003;113:962; with permission.
the glottic closure is only one of the mechanisms of airway protection during
the swallow, its importance is shown by the fact that the maximal glottic (thyroarytenoid and interarytenoid) muscle contraction occurs during the swallow
and by the high incidence of aspiration and penetration identified in patients
who have vocal fold paralysis [22–24]. The simple mechanical benefit of complete glottic closure is confirmed by the immediate benefits in swallowing associated with static vocal fold medialization procedures [25,26].
Glottic insufficiency secondary to vocal fold paralysis may be coupled
with sensory and motor defects, depending on the site of neural injury
(high vagal trunk or isolated recurrent laryngeal nerve). These conditions
may be temporary or permanent. Temporary causes may include stroke,
postintubation trauma, and stretching of the nerves during surgeries of
the neck such as thyroidectomy, anterior-approach cervical spine surgery,
and thoracic surgery. These medical conditions and surgeries also may
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Fig. 3. Glottic insufficiency and arytenoid adduction. (A) Endoscopic view of a paralyzed vocal
fold (left). (B) Endoscopic view after medialization laryngoplasty and arytenoid adduction
(left). (C) Diagram of suture traction vectors (arrows) on the arytenoid muscular process and
vocal process rotation to midline.
lead to permanent nerve deficits. It is not always immediately apparent
whether the damage will be temporary or permanent, and establishing
a prognosis can be problematic. The role of laryngeal electromyography
in determining the status of laryngeal innervation and the prognosis of functional recovery is controversial [27,28]. Fortunately, because of the multiple
therapeutic choices available, a successful rehabilitation strategy can be implemented even with imperfect information regarding recovery prognosis.
Clinical signs of glottic insufficiency include a hoarse and breathy vocal
quality, coughing in response to secretions or oral intake (primarily with
thin liquids), and the inability to produce an adequate clearing cough [29].
When glottic insufficiency is suspected, the patient should be evaluated by
both an otolaryngologist and a speech-language pathologist who specializes
in the evaluation and treatment of voice and swallowing. Evaluation may
include a bedside swallow evaluation to determine the risk of aspiration
with continued oral feeding and probably will continue with imaging studies
SURGICAL TREATMENT OF DYSPHAGIA
825
to define better the extent of dysfunction. The common studies include
videofluoroscopic swallowing study or an endoscopic examination of swallowing, during which the speech-language pathologist examines the patient’s
ability to swallow liquids, purees, and solids and determines the usefulness
of various compensatory maneuvers and behavioral strategies to prevent aspiration and identify evidence of silent aspiration. Although these behavioral and compensatory strategies are effective in many patients, those
who have severe swallowing deficits or cognitive impairments may not be
good candidates for behavioral treatment and may require surgery to avoid
aspiration pneumonia. Vocal fold injection with temporary agents could be
offered to any symptomatic patient as an adjunct to swallow therapy,
because these injections aid in voice stability and cough respiratory function
and improves the mechanics of swallowing.
The spectrum of surgical therapy for glottic insufficiency is quite large
when all the subtle modifications are considered, but the two basic groups
are injection procedures and open laryngeal procedures. Injection procedures use both temporary and permanent injection materials. The choice
of surgical therapy for glottic insufficiency depends on a multitude of factors
including the likelihood of spontaneous normal recovery, the anticipated
time until recovery, the degree of impairment in voice, swallowing, and
coughing, the position of the paretic vocal fold, the patient’s relative tolerance of aspiration and the risk of pneumonia, the patient’s cognitive status,
the patient’s willingness to modify diet and eating habits, and the expected
length of overall survival because of medical conditions. In this article the
authors emphasize the advantages of the currently available procedures
(Table 3) and provide an example of a decision tree to assist in appropriate
treatment triage (Fig. 4).
Management of glottal insufficiency: injection laryngoplasty
Injection laryngoplasty involves the placement of a filler substance into
the paraglottic space occupied by the connective tissues and muscles primarily responsible for glottic closure. The filler material simply occupies space
and displaces the mobile edge of the vocal fold toward the midline, thus
positioning it as close as possible to its phonatory location; this placement
allows vocal fold contact and glottic closure during swallowing, voicing,
and coughing. The injections can be done transcutaneously or transorally
and with flexible or rigid endoscopy. Nearly all patients can be treated in
a clinic setting, but if the patient prefers or if injection precision is essential,
as with polytetrafluoroethylene (a permanent material), a brief general anesthetic can be used. Most injection materials used today would be considered
temporary, but the ease of the technique lends itself to repeat procedures
(see Table 3) [24]. In most cases of injection laryngoplasty, an attempt is
made to over-augment slightly, because bulk loss is anticipated when the injection swelling resolves and injection carrier materials are resorbed (Fig. 5).
826
Table 3
Common vocal fold injection materials
Duration of effect
Advantages
Disadvantages
Human adipose tissue
4 months–permanent
Cymetra (Life Cell,
Branchburg, NJ)
Voice Gel (Bioform
Medical, San Mateo,
CA)
Polytetrafluoroethylene
Micronized acellular dermis
2–12 months
Low antigenicity, similar
to native vocal fold tissue
Low antigenicity
Carboxymethylcellulose
2–3 months
Low antigenicity
Unpredictable resorption and
long-term results
Preparation time, unpredictable
duration
Intermediate duration
Synthetic
Permanent
Long-lasting
Glycosaminoglycan from human
extracellular matrix
Bovine gelatin
4–6 months
Low antigenicity
4–6 weeks
Long track record
Hyaluronic acid gels
Gel foam
Irreversible, foreign body reaction,
unpredictable
Limited history, not effective with
vocal fold scars
Short duration
Data from Kwon TK, Buckmore R. Injection laryngoplasty for management of unilateral vocal fold paralysis. Curr Opin Otolaryngol Head Neck Surg
2004;12(6):538–42; King JM, Simpson CB. Modern injection augmentation for glottic insufficiency. Curr Opin Otolaryngol Head Neck Surg 2007;15(3):153–
8; Courey MS. Injection laryngoplasty. Otolaryngol Clin North Am 2004;37:121–38.
et al
Active component
Fat
SHAMA
Material
827
SURGICAL TREATMENT OF DYSPHAGIA
Signs/symptoms of glottic insufficiency
Evaluation by speech pathologist for
aspiration
Aspiration
No aspiration
Effective compensatory
maneuvers
Acute treatment not necessary
Acute treatment not necessary
Ineffective compensatory
maneuvers
Recovery potential
Injection laryngoplasty
Limited recovery potential
No posterior glottic gap
Medialization thyroplasty
Posterior glottic gap
Medialization thryoplasty with
arytenoid adduction
Fig. 4. Algorithm for treatment of glottic insufficiency.
Management of glottal insufficiency: medialization thyroplasty
Open laryngoplasty and medialization thyroplasty are reserved to treat
permanent conditions of glottic insufficiency and to treat patients in
whom recovery is impossible because of nerve or tissue resection. The available techniques all require the placement of an implant into the same
Fig. 5. Endoscopic view of injection laryngoplasty. The arrow indicates the site of the initial
midcord injection. The needle is at the site of the second injection lateral to the vocal process.
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paraglottic space exploited with injections; however these techniques rely on
the framework of the thyroid cartilage to retain stability. These implants are
intended to be permanent and are incrementally sized and positioned to
procure optimum glottic closure. In most cases the procedures are done
with local anesthesia and intravenous sedation to allow an awake, cooperative patient to assist with phonation during the positioning of the implant.
Several types of implants have been described, all requiring slight modifications in surgical technique but with the same ultimate goal. The quality of
the outcome depends more on the experience of the surgeon than on the
material implanted.
Management of glottal insufficiency: arytenoid adduction
It can be difficult, at times, using either injection techniques or open
aryngoplasty, to close a wide posterior glottic gap completely. This recognized deficiency led to the development of suture arytenoid adduction
(see Fig. 3B, C). Arytenoid adduction first was described as a stand-alone
procedure, but now it almost always is combined with open implant laryngoplasty [30,31]. Arytenoid adduction leads to better and more durable
voice outcomes secondary to more complete glottic closure. This benefit is
manifested in measures such as improved maximum phonation times and
presumably also leads to better swallowing function [31]. Arytenoid adduction, however, is a much more complicated surgical procedure with higher
risks and longer operating times, so its use is limited primarily to patients
who have a wide posterior glottic gap.
Other management techniques: hyoid suspension, epiglottoplasty,
and laryngeal stents
The use of hyoid suspension to improve swallowing is limited currently to
augmentation of glottic closure after supraglottic laryngectomy. In this
setting, it temporarily improves glottic protection during swallowing by
positioning the exposed glottis under the tongue base and may supplement
cricopharyngeal opening with static anterior traction. It has been reported
as a method of dysphagia control, but its role other than in laryngeal cancer
therapy has not been defined.
A variety of other supraglottic surgical procedures have been described to
close the larynx completely or partially. These procedures have not been adopted widely, however, because they are difficult to perform, have high failure
rates, limit or eliminate voicing, and require the placement of a tracheotomy.
One simple technique that has a place in treating recoverable severe dysphagia
is the placement of a laryngeal stent combined with tracheotomy [32]. In this
simple technique the silicone elastomer stent is placed in the glottis and subglottis and is secured with a suture through the laryngeal cartilages. The stent
sits above the tracheotomy tube and acts as a physiologic cork, preventing
SURGICAL TREATMENT OF DYSPHAGIA
829
aspiration. Once the patient has recovered swallowing function, the stent can
be removed, leaving the normal larynx intact.
Total laryngectomy and laryngotracheal separation
Although adult patients develop and acquire medical problems throughout
life, their difficulties with swallowing often stem from a single cause that may
lead to various difficulties. Children, on the other hand, may sustain a single
insult in utero, perinatally, or while young that results in numerous medical
problems leading to dysphagia of multifactorial causes. As in adults, the
impairment of laryngeal and pharyngeal function leads to repeated pulmonary insults such as aspiration pneumonia and to microaspiration leading to
chronic lung damage. This problem is prevalent in patients who have cerebral
palsy, anoxic encephalopathy, and traumatic brain injuries and has a cumulative effect [33]. Pharmacologic treatment and surgical interventions such as the
placement of a tracheotomy may lessen but do not eliminate the morbidity
from chronic aspiration [33]. Aspiration can be prevented in the pediatric population by the complete surgical separation of the airway from the alimentary
tract [20,33]. The pediatric population with permanent injuries such as cerebral palsy will have lifelong and cumulative difficulties with swallowing. These
children merit special consideration when evaluated and should be followed
on a long-term basis by the dysphagia team.
Many dysphagia-associated disease states cannot be managed by simple
surgical treatments, swallowing therapies, or diet modifications and lead
to repeated and intractable aspiration, with a risk of malnutrition and
life-threatening pneumonia. These entities often are neuromuscular disorders or neurologic diseases, such as amyotrophic lateral sclerosis, stroke,
and severe cerebral palsy. They also can occur in patients treated for head
and neck cancer with partial laryngectomy or high-dose radiation therapy,
leading to anatomic and/or functional laryngeal defects. In many of these
patients multiple interventions to control aspiration may have been unsuccessful, or the patients may not be suitable candidates for these interventions. These patients have complex medical, social, and quality-of-life
issues that require consideration, but if prevention of aspiration and its
side effects coincides with the therapy goals, the two best operative options
are laryngotracheal separation and laryngectomy.
Laryngotracheal separation (Fig. 6), which involves complete separation
of the alimentary and respiratory pathways, completely eliminates aspiration [34]. It involves separation of the lower respiratory tract from the upper
aerodigestive tract at the level of the second and third tracheal rings.
It leaves a blind pouch at the proximal end of the trachea and generally is
considered reversible [20]. Although the surgery requires general anesthesia,
it is not considered complex. It is important to realize that this surgery eliminates the ability to phonate, but not the potential to phonate in the future,
should the surgery be reversed. Laryngotracheal separation generally is used
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Fig. 6. Diagram of laryngotracheal separation.
to treat patients who have severe neurologic disease and patients who have
chronic aspiration after major head and neck surgery for cancer. It is well
tolerated but does require a tracheostoma for respiration. Because most
patients undergoing this procedure already have lost the ability to communicate with the voice, the loss of usable speech is not considered a deterrent
for the procedure [34]. The laryngotracheal separation procedure retains an
intact anatomic larynx, which may be valuable in vocal rehabilitation when
the procedure is reversed. Otherwise neurologically intact patients can
improve communication by using an electrolarynx or can be coupled with
tracheoesophageal puncture and voicing valve placement. The retention of
a body part such as the larynx also may have psychologic benefits in
some patients.
A total laryngectomy involves the removal of the larynx, completely and
permanently separating the upper aerodigestive tract from the respiratory
system and eliminating aspiration. It is the best choice for nonverbal
patients and for patients without hope of recovery of laryngeal function.
Tracheotomy tubes and their effect on dysphagia and aspiration
Tracheotomy tubes are a common part of the management of patients
who have complex medical issues. Their primary role is an adjunct to pulmonary support and ventilation, but they frequently are placed in an
attempt to control respiratory secretions and, in some cases, to manage
aspiration. There is no doubt that a tracheotomy tube eases the access to
the lower airway for frequent suctioning and certainly aids in the
SURGICAL TREATMENT OF DYSPHAGIA
831
visualization of the aspiration. A tracheotomy, however, does not prevent
aspiration and may be associated with an increased risk of aspiration.
Nasogastric and percutaneous gastrostomy tubes are used commonly in dysphagic patients for the delivery of nutrition, but aspiration is not totally prevented by the use of these tubes because refluxate from the stomach into the
hypopharynx can be aspirated.
The population of patients predisposed to combined respiratory failure
and dysphagia include those who have brain injuries from trauma or stroke,
acute or progressive neurologic disease, neuromuscular diseases, or multisystem failure caused by infection or other illness [35]. These patients are
more likely to require placement of a tracheotomy because of their underlying disease process. Debate continues around the impact of tracheotomy on
dysphagia and aspiration. Some argue that tracheotomies are associated
with an increased risk of aspiration, because there is an alteration in laryngeal elevation and swallow reflex [35–39]. Some studies of trauma patients
and of patients who have head and neck cancer in the early postsurgical
period, however, have shown that tracheotomy tubes neither increase nor
decrease aspiration [35,40,41]. The impact of tracheal occlusion also has
been controversial. Tracheotomy tube occlusion status was not shown to
influence the presence of aspiration in the early postsurgical period in
patients who had head and neck cancer [42]. Examination of aspiration status with occluded and unoccluded tracheotomy tubes in patients 6 to
8 months after surgery for head and neck cancer, however, demonstrated increased aspiration with unoccluded tracheotomy tubes [42–44]. The reason
for the discrepancy with respect to tracheotomy tube occlusion status and
aspiration between the