Surgical closure of the larynx for intractable aspiration pneumonia: cannula-free care and minimizing the risk of developing trachea-innominate artery fistula

Outcomes of Aspiration Prevention Surgery: A Retrospective Cohort Study Using a Japanese Claims Database

Aspiration prevention surgeries, such as laryngotracheal separation and total laryngectomy are performed to prevent aspiration pneumonia. We aimed to investigate the outcomes of surgery for intractable aspiration and relevant factors. This retrospective cohort study used a nationwide insurance claims database that included company employees and their family members aged < 75 years in Japan. We extracted the data of patients who underwent aspiration prevention surgeries between January 2005 and March 2019. We identified 127 patients (males, 55.9%), of whom 59.8% were aged < 18 years at the surgery. The most common comorbidity was neurological disease (99.2%). The frequency of pneumonia episodes decreased by 1.5 per year after surgery compared with before surgery (p < 0.001). Among patients who received parenteral and enteral nutrition before surgery (n = 92), the adjusted hazard ratio (aHR) for oral intake without parenteral and enteral nutrition was lower in the longer preoperative duration (≥ 14.7 months) for the parenteral and enteral nutrition. However, the difference was not statistically significant (aHR 0.55; 95% confidence interval: 0.15-2.08, p = 0.38). The aHR for oral intake was higher in the ≥ 30 years group than in the < 30 years group (aHR 13.76; 95% confidence intervals: 4.18-42.24; p < 0.001). This study demonstrated that postoperative oral intake was achieved more frequently in patients aged ≤ 30 years than in those aged > 30 years, and supported the effectiveness of aspiration prevention surgery for reducing aspiration pneumonia. Further research is necessary to investigate factors related to postoperative oral intake.

Recurrent pneumonia in three patients with MECP2 duplication syndrome with aspiration as the possible cause

INTRODUCTION

Methyl-CpG binding protein 2 gene (MECP2) is located on the X chromosome (Xq28) and is important for nervous and immune system functioning. Patients with MECP2 duplication syndrome (MDS) have recurrent respiratory infections (RRIs). Although RRIs often occur with MDS because some patients with MDS also have hypoimmunoglobulinemia and duplication of the interleukin-1-receptor-associated kinase-1 gene (IRAK1), which is also located on Xq28, the phenotype of IRAK1 duplication in patients with MDS remains unclear.

METHODS

The clinical course of three patients with MDS who underwent laryngotracheal separation (LTS) at two institutions was summarized.

RESULTS

Three patients with MDS were identified to have recurrent pneumonia characteristic of aspiration pneumonia, sometimes requiring artificial ventilation therapy; they had no other bacterial infections. After LTS, they rarely had pneumonia. In MDS, MECP2 expression increased two-fold naturally, while IRAK-1 expression showed no difference compared with a healthy subject.

CONCLUSIONS

Since RRIs in MDS are thought to be caused by aspiration and not susceptibility to infection previously estimated to be major complication, the evaluation of aspiration is recommended for RRIs for better management of MDS.

Advantage of a higher position of the tracheostoma with glottic closure for preventing complications related to tracheostomy tube: a retrospective cohort study

Background

Surgery to prevent aspiration has complications related to tracheostomy tube, such as the trachea-brachiocephalic artery fistula. Glottic closure procedure makes tracheostoma at a position higher than the first ring of the trachea and theoretically has a potential to prevent such complications owing to a longer distance between the tip of tracheostomy tube and the tracheal membrane adjacent to the brachiocephalic artery. Our aim is to evaluate the safety of glottic closure in neurologically impaired patients by comparing outcomes with laryngotracheal separation.

Methods

This study is a single-center retrospective study from 2004 to 2019, using data of 15 and 12 patients who underwent glottic closure (GC) and laryngotracheal separation (LTS). The primary outcome was the incidence of postoperative complications induced by tracheostomy tube placement and adjustment of the tracheostomy tube position to prevent these complications, such as by converting to a length-adjustable tube and/or placing gauze between the skin and tube flange. Additionally, we analyzed the anatomical relationship between the tracheostomy tube tip and brachiocephalic artery and measured the distance between them using postoperative CT images.

Results

No patients in either group had trachea-brachiocephalic artery fistula. Erosion or granuloma formation occurred in 1 patient (7%) and 4 patients (33%) in the GC and LTS groups, respectively. Adjustment of the tracheostomy tube was needed in 2 patients (13%) and 6 patients (50%) in the GC and LTS groups. CT revealed a higher proportion of patients with the tracheostomy tube tip superior to the brachiocephalic artery in GC than LTS group. The mean tracheostoma-brachiocephalic artery distance was 40.8 and 32.4 mm in the GC and LTS groups.

Conclusions

Glottic closure reduces the risk of postoperative complications related to a tracheostomy tube. This may be due to the higher position of the tracheostoma at the level of the cricoid cartilage, increasing the distance between the tracheostoma and brachiocephalic artery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01505-2.

Challenge for management without tracheostomy tube after laryngo-tracheal separation in children with neurological disorders

OBJECTIVES

The present study analyzed surgical outcomes of laryngotracheal separation (LTS) in children with neurological disorders. The purpose of this study was to investigate respiratory impairment and severe complications after LTS in children, and identify the possibility of permanent tracheostomy without a tracheostomy tube as the safest respiratory management method.

METHODS

Twenty-eight patients (male:female = 16:12) with neurological disorders (6 months to 32 years) who underwent LTS between January 2012 and April 2018 were reviewed. Tracheal diameter, Cobb angle, and sternocervical spine distance (SCD) were measured to assess the potential risk and possibility of removing tracheostomy tube management.

RESULTS

Tracheostomy tube could be removed shortly after LTS in 57% (16/28). However, nine of these patients developed respiratory problems that required tracheostomy tube placement 2 years after LTS. New requirements for a tracheostomy tube as a stent were strongly correlated with SCD (P < .05, odds ratio > 1) as well as tracheal deformity.

CONCLUSIONS

Respiratory management in neurologically impaired children after LTS without a tracheostomy tube is challenging because thoracic deformity during physical growth affects tracheal disfiguration. Thoracic deformities and progression of scoliosis should be considered in respiratory management approaches in children with neurological disorders, and long-term follow-up by computed tomography is necessary.

LEVEL OF EVIDENCE

IV.

[Effect of laryngeal closure on recurrent aspiration pneumonia in patients with neurodegenerative disease]

Three patients with neurodegenerative diseases who had developed repeated aspiration pneumonia underwent laryngeal closure, a surgical procedure at the larynx to prevent aspiration. None of these patients have developed aspiration pneumonia since the procedure. One patient needed endoscopic suction and cough assist machine to clear thick sputum, because tracheostomy bypassed the upper airway and so prevented moisturization of inhaled air. While two patients achieved freedom from tracheal cannulation, one needed continued cannulation because of narrowing of the stoma due to improvements in the nutritional condition. One patient was able to resume oral intake. Although the right timing to perform the procedure and optimal care along with long-term observation are important, laryngeal closure is an effective option for patients with neurodegenerative diseases to prevent recurrent aspiration pneumonia.

Choice of Aspiration Prevention Surgery for Patients With Neuromuscular Disorders: Report of Three Cases

Dysphagia, one of the major complications of neuromuscular diseases such as Parkinson's disease and amyotrophic lateral sclerosis (ALS), decreases quality of life and may lead to malnutrition or aspiration pneumonia. Although recent reports have suggested that surgical aspiration prevention improves quality of life and enables oral intake, the selection of appropriate aspiration prevention techniques has rarely been discussed. In this report, we present the cases of three patients with neuromuscular diseases who underwent surgical aspiration prevention; we selected the surgical techniques based on analysis of the dysphagia mechanisms, disease progression, and general condition in each case. Case 1 was a 55-year-old man with multiple system atrophy (MSA) and presented with dysphagia associated with insufficient upper esophageal sphincter (UES) relaxation. We performed central-part laryngectomy, which was able to improve UES relaxation. Case 2 was a 79-year-old man with progressive supranuclear palsy who presented with respiratory disorder and dysphagia. Glottic closure under local anesthesia was selected because he also had acute hepatobiliary dysfunction and methicillin-resistant Staphylococcus aureus pneumonia with pleural effusion. Case 3 was a 75-year-old man with ALS and presented with respiratory disorder and mild dysphagia. Subglottic closure with total cricoidectomy was selected because his dysphagia was expected to worsen due to tracheostomy and disease progression. We also summarize the characteristics of the aspiration prevention surgical techniques based on our cases and on literature review. The causes of dysphagia, including insufficient UES opening during swallowing, weak pharyngeal constriction, velopharyngeal insufficiency, and inadequate laryngeal elevation, should be assessed by detailed examination before surgery, and the type of aspiration prevention surgery should be selected based on patient swallowing function and general condition.

A laryngeal closure technique for the treatment of patients with head and neck cancer

Background

In 2008, Kano developed a new laryngeal closure technique (Kano's method) for the treatment of severe aspiration. The aim of this study was to evaluate the safety and efficacy of this technique in patients with head and neck cancer.

Methods

Since June 2014 until March 2018, six patients underwent Kano's method for management of severe aspiration after the treatment of head and neck cancers. The anterior parts of the thyroid and the cricoid cartilages were excised widely. The glottis was closed by suturing bilateral vocal folds and reinforced by the sternohyoid muscle. A tracheostoma was created with skin flaps, subglottic mucosal flaps, and stumps of cricoid and trachea cartilages.

Results

No severe complications were observed after the surgery. Oral intake improved without developing aspiration.

Conclusions

Kano's method can provide satisfactory functional results with minimal invasion for treating severe aspiration after advanced surgery, chemotherapy, and/or chemoradiotherapy, in patients with head and neck cancer.

Level of Evidence

4

Respiratory illness in children with disability: a serious problem?

Key points

Educational aims

Children with neurocognitive impairment often present with chronic or recurrent respiratory problemshttp://ow.ly/uqiG306pE9B