Tracheoesophageal Diversion and Laryngotracheal Separation Procedures for Radiotherapy-Related Intractable Aspiration Pneumonia in Nasopharyngeal Carcinoma.

Background: Intractable aspiration and aspiration pneumonia are complications after radiotherapy for nasopharyngeal carcinoma (NPC), and they may be life-threatening in severe cases. In the past, the efficacy of controlling aspiration and aspiration pneumonia in such patients was not ideal. Objectives: We aimed to evaluate the effect of tracheoesophageal diversion and laryngotracheal separation (TED-LTS) procedures for these patients. Material and Methods. We retrospectively analyzed the medical data of five patients with intractable aspiration and recurrent aspiration pneumonia caused by NPC radiotherapy who underwent TED-LTS surgery. The patients were evaluated in terms of aspiration pneumonia control, body weight improvement, removal of tube feeding, oral feeding, and complications. Results: Intractable aspiration and aspiration pneumonia were completely controlled in all cases, and the patients' body weight increased from 46.46 ± 4.6 (38.9-50.3) kg to 55.32 ± 2.7 (51.4-56.7) kg. Four patients were able to consume an oral semisolid diet, and one patient maintained an oral liquid diet. Tube feeding was not required in 4 patients. One patient developed postoperative esophageal fistula, which improved after conservative treatment. Conclusion: TED-LTS is effective for intractable aspiration and aspiration pneumonia caused by NPC radiotherapy and can be used to restore partial oral feeding. However, strict surgical indications should be followed.

A Giant Esophageal Epiphrenic Diverticulum Causing Dysphagia, Fungal Infection and Aspiration Pneumonia in an Elderly Patient.

Esophageal epiphrenic diverticulum is a rare condition. We present a case of a 70-year male with no known comorbidities who presented with dysphagia, cough, fever, and weight loss for 3 months. CT chest with contrast showed an out-pouching arising from the distal dorsal oesophagus, 15.6 cm long with 0.9 cm neck, containing food particles causing compression and consolidation of adjacent lung segments. His upper gastrointestinal endoscopy showed a large diverticulum arising at 30 cm from incisors with overlying ulcerated and necrotic mucosa. A biopsy of diverticular mucosa showed fungal hyphae and spores and was negative for malignancy. The patient was given antifungals and showed significant improvement of symptoms but considering the huge size of the diverticulum, he was referred to a thoracic surgeon. Key Words: Epiphrenic diverticulum, Dysphagia, Aspiration pneumonia, Fungal infection.

An uncommon etiological factor for aspiration pneumonitis caused by spontaneous sphenoid sinus meningoencephalocele with cerebrospinal fluid rhinorrhea: a case report.

BACKGROUND: Aspiration pneumonitis is an inflammatory disease of the lungs which is difficult to diagnose accurately. Large-volume aspiration of oropharyngeal or gastric contents is essential for the development of aspiration pneumonitis. The role of cerebrospinal fluid (CSF) rhinorrhea is often underestimated as a rare etiological factor for aspiration in the diagnosis process of aspiration pneumonitis. CASE PRESENTATION: We present a case of a patient with 4 weeks of right-sided watery rhinorrhea accompanied by intermittent postnasal drip and dry cough as the main symptoms. Combined with clinical symptoms, imaging examination of the sinuses, and laboratory examination of nasal secretions, she was initially diagnosed as spontaneous sphenoid sinus meningoencephalocele with CSF rhinorrhea, and intraoperative endoscopic findings and postoperative pathology also confirmed this diagnosis. Her chest computed tomography showed multiple flocculent ground glass density shadows in both lungs on admission. The patient underwent endoscopic resection of meningoencephalocele and repair of skull base defect after she was ruled out of viral pneumonitis. Symptoms of rhinorrhea and dry cough disappeared, and pneumonitis was improved 1 week after surgery and cured 2 months after surgery. Persistent CSF rhinorrhea caused by spontaneous sphenoid sinus meningoencephalocele was eventually found to be a major etiology for aspiration pneumonitis although the absence of typical symptoms and well-defined risk factors for aspiration, such as dysphagia, impaired cough reflex and reflux diseases. CONCLUSIONS: We report a rare case of aspiration pneumonitis caused by spontaneous sphenoid sinus meningoencephalocele with CSF rhinorrhea, which can bring more attention and understanding to the uncommon etiology for aspiration, so as to make more accurate diagnosis of the disease and early surgical treatment.

Chronic Aspiration Pneumonitis Caused by Spontaneous Cerebrospinal Fluid Fistulae of the Skull Base.

OBJECTIVES/HYPOTHESIS: Spontaneous cerebrospinal fluid (CSF) leaks of the skull base are associated with obesity, multiparity, and elevated intracranial pressure. Although spontaneous CSF leaks often present with rhinorrhea, they can be an underdiagnosed cause of chronic aspiration pneumonitis, a complication that has not been previously reported in detail. STUDY DESIGN: Retrospective case series. METHODS: The authors retrospectively reviewed all patients undergoing surgical repair of CSF fistulae at the University of Southern California between 2011 and 2018 to identify those presenting with pulmonary symptoms including dyspnea, aspiration, chronic cough, and shortness of breath caused by chronic noniatrogenic CSF pneumonitis. RESULTS: Symptomatic chronic pneumonitis was evident in six of 20 patients with spontaneous CSF rhinorrhea. Five women (mean body mass index = 36) had CSF leaks arising from the fovea ethmoidalis (n = 4) and lateral sphenoid region (n = 1). One man had a middle fossa floor dehiscence draining through the eustachian tube. All patients had bilateral ground-glass opacities in their lungs on computed tomography imaging that were attributed to spontaneous CSF fistulae arising from noniatrogenic skull base defects, and one patient underwent a biopsy of a lung lesion at another hospital showing chronic bronchiolitis and adjacent peribronchiolar metaplasia. Five patients underwent endoscopic endonasal repair using an autologous fascial graft and pedicled nasoseptal flap, and one underwent craniotomy for repair. All patients underwent successful repair with no complications or evidence of recurrence. Upon repair of the spontaneous CSF leaks, both pneumonitis symptoms and ground-glass opacities on imaging resolved in all six cases. CONCLUSIONS: Skull base CSF fistulae should be considered as a reversible cause of chronic pneumonitis that is not alleviated or worsens with standard treatment. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:462-466, 2021.

Two cases of glottic closure for refractory aspiration pneumonia after vertical partial laryngectomy.

Vertical partial laryngectomy is a well-established surgical procedure for early glottic cancers with acceptable functional and oncological outcomes. However, on a long-term basis, aspiration might be a serious problem with aging. Here we presented two cases of refractory aspiration pneumonia after vertical laryngectomy. Case 1: A 76-year old gentleman with a past history of malignant lymphoma treated by chemotherapy and radiotherapy had glottic cancer, which was treated by repeated vertical partial laryngectomies. Although glottic caner had been well controlled, he started to suffer from refractory aspiration pneumonia. Since his cervical skin was very thin and hard and his general condition was poor, we employed modified Kano's method for glottic closure. Case 2: A 87-year old Japanese male had a past history of glottic cancer treated by radiotherapy and vertical partial laryngectomy. He was repeatedly hospitalized for severe aspiration pneumonia. At the age of 87, he had second primary oropharyngeal cancer. Kano's method was simultaneously performed at the time of resection of oropharyngeal cancer. Postoperative courses were uneventful without sign of leakage in both cases. The patients started oral intake 2 weeks after the surgery. They have been alive without aspiration pneumonia and takes normal diet.

Laryngotracheal separation in pediatric patients: 13-year experience in a reference service.

OBJECTIVE: To evaluate clinical stability of neurologically impaired children and adolescents with recurrent pneumonia submitted to laryngotracheal separation. METHODS: Between October 2002 and June 2015, 92 neurologically impaired children from a reference service, with median age of 68.5 months were submitted to laryngotracheal separation. Data were evaluated and statistical analysis was made by Student's t test and Pearson's χ2 test (significance level adopted of 95%). RESULTS: Fifty-three children were male (57.6%). Forty-six children required admission to intensive care, and 42.4% needed mechanical ventilation. We observed that 90.2% of patients were exclusively fed by gastrostomy and 72.4% of the gastrostomies were performed before the tracheal surgery. Thirteen (14.1%) children had postoperative complications as follows: fistulae (5.4%), bleeding (4.3%), granuloma (2.2%) and stenosis (3.2%). A total of 24 patients had pneumonia in the postoperative period (26.1%), but there was a significant drop in occurrence of this condition after surgery (100% versus 26.1%; p<0.001). Twenty-three patients (25%) died. Postoperative complications were similar when comparing patients who died and those that presented good outcome (16.7% versus 13.2%; p=0.73). CONCLUSION: When well-indicated, the laryngotracheal separation reduces the incidence of postoperative pulmonary infections, thus improving quality of life and reducing admissions to hospital. Laryngotracheal separation should be indicated as a primary procedure in patients with cerebral palsy and recurrent aspiration pneumonia.

Laryngotracheal separation in pediatric patients: 13-year experience in a reference service / Separação laringotraqueal em pacientes pediátricos: 13 anos de experiência em um serviço de referência

ABSTRACT Objective: To evaluate clinical stability of neurologically impaired children and adolescents with recurrent pneumonia submitted to laryngotracheal separation. Methods: Between October 2002 and June 2015, 92 neurologically impaired children from a reference service, with median age of 68.5 months were submitted to laryngotracheal separation. Data were evaluated and statistical analysis was made by Student's t test and Pearson's χ2 test (significance level adopted of 95%). Results: Fifty-three children were male (57.6%). Forty-six children required admission to intensive care, and 42.4% needed mechanical ventilation. We observed that 90.2% of patients were exclusively fed by gastrostomy and 72.4% of the gastrostomies were performed before the tracheal surgery. Thirteen (14.1%) children had postoperative complications as follows: fistulae (5.4%), bleeding (4.3%), granuloma (2.2%) and stenosis (3.2%). A total of 24 patients had pneumonia in the postoperative period (26.1%), but there was a significant drop in occurrence of this condition after surgery (100% versus 26.1%; p<0.001). Twenty-three patients (25%) died. Postoperative complications were similar when comparing patients who died and those that presented good outcome (16.7% versus 13.2%; p=0.73). Conclusion: When well-indicated, the laryngotracheal separation reduces the incidence of postoperative pulmonary infections, thus improving quality of life and reducing admissions to hospital. Laryngotracheal separation should be indicated as a primary procedure in patients with cerebral palsy and recurrent aspiration pneumonia.

RESUMO Objetivo: Avaliar a estabilidade clínica da criança e do adolescente neuropata com episódios de pneumonia de repetição submetidos a procedimento cirúrgico de separação laringotraqueal. Métodos: Entre outubro 2002 a junho 2015, 92 crianças neuropatas de um único serviço com idade mediana de 68,5 meses foram submetidas à separação laringotraqueal. Os dados foram avaliados e foi realizada análise estatística pelo teste t de Student e pelo teste do χ2 de Pearson, com nível de significância adotado de 95%. Resultados: Dentre as 92 crianças, 53 eram do sexo masculino (57,6%). Quarenta e seis crianças necessitaram de internação em unidade de terapia intensiva, e 42,4% fizeram uso de ventilação mecânica. Dessas crianças, 90,2% alimentavam-se exclusivamente via gastrostomia, e 72,4% foram realizadas antes da separação laringotraqueal. As complicações pós-operatórias ocorreram em 13 crianças (14,1%), na seguinte ordem: fístula (5,4%), sangramento (4,3%), granuloma (2,2%) e estenose (3,2%). Observaram-se 24 episódios de pneumonia no período pós-operatório (26,1%). Houve diminuição significativa de ocorrência de pneumonias após a cirurgia (100% versus 26,1%, p<0,001). Óbito foi registrado em 23 pacientes (25%). A frequência de complicações pós-operatórias foi semelhante entre os pacientes que evoluíram ou não para óbito (16,7% versus 13,2%; p=0,73). Conclusão: A cirurgia bem indicada reduz o número de infecção pulmonar após o procedimento, melhorando a qualidade de vida desses pacientes e, consequentemente, reduzindo o número de internações. A separação laringotraqueal deve ser indicada como procedimento primário nos pacientes com paralisia cerebral e episódios repetidos de pneumonia aspirativa.

Diagnosis and Management of Laryngotracheoesophageal Cleft.

Laryngotracheoesophageal cleft (LTEC) is a rare anatomic cause of aspiration in the newborn and infant. The clinical presentation of infants with LTEC is variable and will usually vary with the degree of anatomic communication between the airway and esophagus. The diagnosis of LTEC is often challenging, particularly in cases where the presentation and pathology are more subtle. Management of LTEC depends upon the clinical presentation, degree of aspiration, and anatomic depth of the cleft. The goal of this review is to present the clinician with a practical approach to diagnosis and management of this rare but challenging congenital airway anomaly.

Vagotomy decreases the neuronal activities of medulla oblongata and alleviates neurogenic inflammation of airways induced by repeated intra-esophageal instillation of HCl in guinea pigs.

Neuronal activity in the medulla oblongata and neurogenic inflammation of airways were investigated in a guinea pig model induced by repeated intra-esophageal instillation of hydrochloric acid (HCl) after vagotomy. Unilateral vagotomy was performed in the vagotomy group, while a sham-operation was performed in the sham group. Operation was not conducted in sham control group. Airway inflammation was observed with hematoxylin and eosin (HE) staining. C-fos protein was measured by immunohistochemistry (IHC) and Western blot (WB). Substance P was examined by IHC and enzyme-linked immuno sorbent assay (ELISA). Airway microvascular permeability was detected by evans blue dye (EBD) fluorescence. Inflammation of airway was observed in the trachea and bronchi after chronic HCl perfusion into the lower esophagus, and was alleviated after unilateral vagotomy. C-fos expression in the medulla oblongata was lower in the vagotomy group compared to the sham control and sham groups. Substance P-like immunoreactivity (SP-li), concentration and microvascular leakage in airway were lower in the vagotomy group than that in the other groups. Our results suggest that vagotomy improved neurogenic inflammation of airways and decreased neuronal activities, the afferent nerves and neurons in medulla oblongata may be involved in neurogenic inflammation of airways mediated by esophageal-bronchial reflex.

Therapeutic intervention in oropharyngeal dysphagia.

Oropharyngeal dysphagia is a frequent consequence of several medical aetiologies, and even considered part of the normal ageing process. Early and accurate identification provides the opportunity for early implementation of dysphagia treatments. This Review describes the current state of the evidence related to dysphagia therapies - focusing on treatments most clinically utilized and of current interest to researchers. Despite successes in select studies, the level of evidence to support the efficacy of these treatments remains limited. Heterogeneity exists across studies in both how interventions are administered and how their therapeutic value is assessed, thereby making it difficult to establish external validation. Future work needs to address these caveats. Also, to be most efficacious, dysphagia therapies need to account for influences from pre-morbid patient characteristics as these factors have potential to increase the risk of dysphagia and the resulting complications of aspiration, malnutrition and psychological burden. Dysphagia therapies therefore need to incorporate the medical aetiology that is at its root, the resulting swallow physiology captured from comprehensive clinical and/or instrumental assessments, and the existing needs and supports of patients.

Total laryngectomy for management of chronic aspiration pneumonia in a myopathic dog.

A 5-month-old female pit bull terrier dog evaluated for ataxia, progressive regurgitation, and recurrent aspiration pneumonia had markedly elevated creatine kinase activity, non-inflammatory generalized myopathy, and severe esophageal dysmotility. A narrow-field total laryngectomy was performed. The dog is doing well 30 months after surgery, and no longer has episodes of aspiration pneumonia, despite intermittent regurgitation. This case represents the first application of total laryngectomy for the prevention of chronic recurrent aspiration pneumonia in the dog.

Laryngectomie totale pour la gestion d'une pneumonie par aspiration chronique chez un chien myopathique. Une chienne Pit Bull Terrier âgée de 5 mois évaluée pour de l'ataxie, de la régurgitation progressive et une pneumonie par aspiration récurrente présentait une activité de la créatine kinase particulièrement élevée, une myopathie généralisée non inflammatoire et un trouble de motilité de l'œsophage grave. Une laryngectomie totale à champ étroit a été réalisée. La chienne se porte bien 30 mois après la chirurgie et n'a plus d'épisodes de pneumonie par aspiration, malgré une régurgitation intermittente. Ce cas représente la première application d'une laryngectomie totale pour la prévention d'une pneumonie par aspiration chronique récurrente chez un chien.(Traduit par Isabelle Vallières).

[Safety and efficacy of surgical closure of the larynx for recurrent aspiration pneumonia in persons with severe motor and intellectual disabilities: a comparative study with tracheoesophageal diversion].

OBJECTIVE: We retrospectively investigated the efficacy and complications of surgical closure of the larynx (SCL) for recurrent aspiration pneumonia in comparison with tracheoesophageal diversion. METHODS: The subjects were persons with severe motor and intellectual disabilities (SMID) who had undergone surgery for recurrent aspiration pneumonia between 1994 and 2011: A 8 SCL patients group and a 16 tracheoesophageal diversion patients group. We investigated two groups the lower respiratory infection incidence, length of hospital stay for the surgery, postoperative complications, and rate of cannula withdrawal, by reviewing medical records. RESULTS: Both the SCL and the tracheoesophageal diversion group showed a reduction in the incidence of infection after surgery, indicating that the efficacy of SCL was equivalent to that of tracheoesophageal diversion in preventing aspiration pneumonea. The SCL group showed a reduction in the length of hospital stay and an increased rate of cannula withdrawal as compared with the tracheoesophageal diversion group. CONCLUSION: The efficacy of SCL was equivalent to that of tracheoesophageal diversion in preventing aspiration for SMID. We consider SLC to have potential for reducing the burden on patients.

Device Life of Two Generations of Provox Voice Prostheses.

BACKGROUND: Tracheoesophageal voice prostheses are invaluable for speech rehabilitation in patients who have received total laryngectomy, but device failure impedes communication and creates psychosocial and financial burdens. This study compares the Provox 2 and Provox Vega voice prostheses on the parameter of device life. METHODS: This was a retrospective observational study of 21 patients with 181 device replacements at an academic tertiary care medical center. Disparity in device life and factors that may influence device life were analyzed. RESULTS: The mean device life for Provox 2, at 115.6 days (SE = 5.8), was longer than for Provox Vega, at 65.1 days (SE = 7.5) (P < .001). CONCLUSIONS: Device longevity was greater for Provox 2 over Provox Vega. These results will facilitate the design of prospective studies to assess reasons for variations in device life between patients and device types.

Anterior mediastinal tracheostomy with a median mandibular splitting approach in a Larsen syndrome patient with posterior cervical arthrodesis.

Larsen syndrome is a rare congenital connective tissue disorder characterized by multiple joint dislocations. A novel anterior mediastinal tracheostomy with a median mandibular splitting approach is presented for the treatment of airway obstruction in a Larsen syndrome patient with posterior cervical arthrodesis.

Clinical outcomes of tracheoesophageal diversion and laryngotracheal separation for aspiration in patients with severe motor and intellectual disability.

CONCLUSIONS: Tracheoesophageal diversion (TED) and laryngotracheal separation (LTS) can prevent aspiration pneumonia and improve the morbidity of patients with severe motor and intellectual disability (SMID). By improving hospitalization rates and care needs, the quality-of-life can be improved for the patients and their parents. OBJECTIVES: This study evaluated the clinical outcomes of TED and LTS in patients with intractable aspiration and SMID. METHODS: This study retrospectively reviewed patients with SMID and intractable aspiration pneumonia who underwent TED or LTS at the institution between January 2008 and January 2015. It assessed the frequency of sputum suctioning, the number of pre-operative and post-operative hospitalizations, the operative time, and complications. RESULTS: Forty patients were identified during the study period. After surgery, there were significant reductions in the frequency of secretion suctioning (from 165.0 times/day to 33.0 times/day) and the number of hospitalizations because of aspiration pneumonia (from 5.4 times/year to 0.2 times/year). A tracheocutaneous fistula occurred in one (2.5%) patient, and two (5.4%) patients developed tracheoinnominate artery fistulas. In the latter group, the innominate arteries were successfully ligated and endovascular embolization was performed.

Solitary lung masses due to occult aspiration.

BACKGROUND: Aspiration occurs commonly, at times clinically occult, and is recognized to cause a widening spectrum of lung disorders. Presentation of aspiration as a lung mass has not been described. METHODS: Among cases of aspiration-related pulmonary diseases diagnosed at Mayo Clinic (Rochester, Minn) from 2007 to 2013, 3 patients were identified to have presented with a solitary lung mass lesion. RESULTS: The age of 3 patients, all men with a history of gastroesophageal reflux disease, ranged from 53 to 65 years. All patients presented with dyspnea, cough, and intermittent fevers. Chest computed tomography in each patient demonstrated malignant-appearing solitary lung mass, cavitated in 2 patients. Two patients underwent positron emission tomography, which showed intense fluorodeoxyglucose uptake in the lung mass for both. Surgical lung resection revealed acute and organizing pneumonia with giant cell reaction to foreign material, consistent with aspiration in all 3 patients. None of these lung masses were located in the "dependent" (posterior or basal) lung zones. These patients were managed with antireflux medical therapy; 1 patient underwent a Nissen fundoplication procedure for recurrent symptoms. No additional aspiration-related complications occurred during the follow-up period ranging from 24 to 84 months. CONCLUSIONS: Aspiration-related pulmonary complications can present as a solitary lung mass that may not be located in dependent lung zones, which have traditionally been associated with aspiration-related pulmonary diseases.