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Imaizumi M, Suyama K, Goto A, Hosoya M, Murono S. Flowchart for selecting an appropriate surgical airway in neurologically impaired pediatric intubated patients: a case series. Braz J Otorhinolaryngol 2023; 89:101290. [PMID: 37467656 PMCID: PMC10372357 DOI: 10.1016/j.bjorl.2023.101290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/29/2023] [Indexed: 07/21/2023] Open
Abstract
OBJECTIVE Medical advances have resulted in increased survival rates of neurologically impaired children who may require mechanical ventilation and subsequent tracheostomy as a surgical airway. However, at present, there is no definite consensus regarding the timing and methods for placement of a surgical airway in a neurologically impaired intubated child who needs to be cared for over a long-term period. We therefore created a flowchart for the selection of a surgical airway for Neurologically Impaired Pediatric Patients (NIPPs). METHODS The flowchart includes information on the patients' backgrounds, such as intubation period, prognosis related to reversibility, and history of aspiration pneumonia. To evaluate the importance of the flowchart, first we conducted a survey of pediatricians regarding selection of a surgical airway, and we also evaluated the appropriateness of the flowchart among pediatricians and caregivers through questionnaire surveys which include satisfaction with the decision-making process, and postoperative course after discharge. RESULTS A total of 21 NIPPs with intubation underwent surgery and a total of 24 participants (14 pediatricians and 10 caregivers) completed the survey. The answers regarding the importance of the flowchart showed that eleven pediatricians had experience selecting of surgical airways, nine of whom had had experiences in which they had to make a difficult decision. The answers regarding the appropriateness of the flowchart revealed that all pediatricians and caregivers were satisfied with the decision-making process and postoperative course after discharge using the flowchart. CONCLUSIONS The present study demonstrated the effectiveness of our flowchart for selecting an appropriate surgical airway in NIPP. By referring to our flowchart, pediatricians and caregivers are likely to be able to select an appropriate surgical airway, leading to increased satisfaction with the decision-making process and postoperative course. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Mitsuyoshi Imaizumi
- Fukushima Medical University, School of Medicine, Department of Otolaryngology, Fukushima, Japan.
| | - Kazuhide Suyama
- Fukushima Medical University, School of Medicine, Department of Pediatrics, Fukushima, Japan
| | - Aya Goto
- Fukushima Medical University, Health Information and Epidemiology Center for Integrated Science and Humanities, Fukushima, Japan
| | - Mitsuaki Hosoya
- Fukushima Medical University, School of Medicine, Department of Pediatrics, Fukushima, Japan
| | - Shigeyuki Murono
- Fukushima Medical University, School of Medicine, Department of Otolaryngology, Fukushima, Japan
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Ueha R, Magdayao RB, Koyama M, Sato T, Goto T, Yamasoba T. Aspiration prevention surgeries: a review. Respir Res 2023; 24:43. [PMID: 36747240 PMCID: PMC9901145 DOI: 10.1186/s12931-023-02354-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/31/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Severe dysphagia can cause intractable pneumonia and lead to life-threatening conditions. Intractable aspiration can occur despite medical management for aspiration prevention. Surgical intervention is indicated for intractable aspiration to prevent potentially life-threatening complications. Since the 1970s, several surgical treatments to prevent aspiration have been reported, and various aspiration prevention surgeries have been introduced, but little is known about them or their benefits. This is a review of the types of aspiration prevention surgery, with the aim of increasing aspiration prevention surgery awareness and their clinical outcomes among medical professionals, which will guide the choices of aspiration prevention surgeries for patients with intractable aspiration. MAIN BODY Aspiration prevention surgeries can be categorized into three according to their approaches: removal of the larynx, altering the structure of the trachea, and closure of the larynx. Aspiration prevention surgeries to remove the larynx include total and central-part laryngectomy. Aspiration prevention surgeries to alter the structure of the trachea include tracheoesophageal diversion, laryngotracheal separation, and the tracheal flap method. Surgeries to close the larynx can be divided into supraglottic laryngeal closure, glottic laryngeal closure, and subglottic laryngeal closure. Aspiration prevention surgeries prevent aspiration and increase oral intake in 50-80% of patients. Most patients lose vocal function after aspiration prevention surgeries; however, some patients who have undergone total laryngectomy or laryngotracheal separation restored their speech function through tracheoesophageal puncture and use of voice prosthesis. Postoperative suture failure is frequent after epiglottic flap closure and total laryngectomy but rare after central-part laryngectomy, laryngotracheal separation, glottic closure, and subglottic closure. Furthermore, aspiration prevention surgeries improve the quality of life of patients and their caregivers by decreasing suctioning frequency. CONCLUSIONS In this review, we described the history and development of aspiration prevention surgeries. Medical professionals need to continually improve their knowledge and skills to facilitate appropriate aspiration prevention surgeries according to patient condition.
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Affiliation(s)
- Rumi Ueha
- Swallowing Center, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan. .,Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Redentor B. Magdayao
- grid.26999.3d0000 0001 2151 536XDepartment of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan ,Department of Otorhinolaryngology-Head and Neck Surgery, Eastern Visayas Medical Center, Tacloban, Philippines
| | - Misaki Koyama
- grid.26999.3d0000 0001 2151 536XDepartment of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taku Sato
- grid.26999.3d0000 0001 2151 536XDepartment of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takao Goto
- grid.26999.3d0000 0001 2151 536XDepartment of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Yamasoba
- grid.26999.3d0000 0001 2151 536XDepartment of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Sugitate R, Muramatsu K, Ogata T, Goto M, Hayashi S, Sawaura N, Kawada-Nagashima M, Matsui A, Yamagata T. Recurrent pneumonia in three patients with MECP2 duplication syndrome with aspiration as the possible cause. Brain Dev 2022; 44:486-491. [PMID: 35351320 DOI: 10.1016/j.braindev.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/27/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Ryo Sugitate
- Department of Pediatrics, Japanese Red Cross Maebashi Hospital, Maebashi, Japan
| | | | - Tomomi Ogata
- Department of Pediatrics, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Masahide Goto
- Department of Pediatrics, Jichi Medical University, Tochigi, Japan
| | - Shin Hayashi
- Department of Genetics, Institute for Developmental Research, Aichi Developmental Disability Center, Kasugai, Japan; Department of Molecular Cytogenesis, Medical Research Institute and Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Noriko Sawaura
- Department of Pediatrics, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Atsushi Matsui
- Department of Pediatrics, Japanese Red Cross Maebashi Hospital, Maebashi, Japan
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Raval TH, Elliott CA. Botulinum Toxin Injection to the Salivary Glands for the Treatment of Sialorrhea with Chronic Aspiration. Ann Otol Rhinol Laryngol 2017; 117:118-22. [DOI: 10.1177/000348940811700209] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Chronic aspiration of salivary secretions can cause major pulmonary morbidity in neurologically impaired patients. Many treatments are proposed to address these problems, some with significant side effects. Botulinum toxin type A injection into the salivary glands is known to reduce salivary flow without major complications. Few reports exist regarding the use of this treatment in the prevention of recurrent aspiration pneumonia. We studied the effects of this treatment for patients with recurrent aspiration pneumonia. Methods We performed a chart review of 12 patients, ranging in age from 7 months to 37 years, treated with botulinum toxin injections at a single tertiary care institution. A caregiver telephone questionnaire was also administered. The numbers of pulmonary infections and hospitalizations before and after the initiation of treatment were compared. Results Nine of 12 patients reported improvement in the numbers of hospitalizations and pulmonary infections following botulinum toxin injections. Reduction in the use of anticholinergic medication and reduced pulmonary toilet requirements were also noted. There were no complications of treatment. Conclusions Botulinum toxin injection into the salivary glands can be effective in reducing pulmonary morbidity in many neurologically impaired patients. This relatively simple technique offers an alternative to the use of anticholinergic medication and may obviate the need for more invasive surgical treatment in certain patients.
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Affiliation(s)
- Tejas H. Raval
- Department of Otolaryngology-Head and Neck Surgery, Tufts-New England Medical Center and Floating Hospital for Children, Boston, Massachusetts
| | - Clark A. Elliott
- Department of Otolaryngology-Head and Neck Surgery, Tufts-New England Medical Center and Floating Hospital for Children, Boston, Massachusetts
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Faria J, Harb J, Hilton A, Yacobucci D, Pizzuto M. Salivary botulinum toxin injection may reduce aspiration pneumonia in neurologically impaired children. Int J Pediatr Otorhinolaryngol 2015; 79:2124-8. [PMID: 26478107 DOI: 10.1016/j.ijporl.2015.09.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 09/15/2015] [Accepted: 09/23/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Neurologically impaired children often drool and aspirate saliva leading to recurrent aspiration pneumonia and frequent hospitalizations. Salivary botulinum toxin injection is known to reduce sialorrhea. This study evaluates whether this intervention affects the frequency and duration of respiratory infections including aspiration pneumonia and hospitalizations in neurologically impaired children. METHODS Retrospective review of patients treated with salivary botulinum toxin at a tertiary care pediatric hospital from January 2009 to December 2013. Each patient was their own control and 180 day pre-injection and post-injection time periods were compared. Outcomes evaluated included: number of hospital days, intensive care unit days, days of antibiotic treatment, chest X-rays, and infiltrates on chest X-ray. RESULTS 13 patients accumulated 539 hospital days. All children were gastrostomy tube dependent. 54% were tracheostomy tube dependent. Amongst all patients, the total hospital days decreased from 385 to 154 (P=0.02), the mean days treated with antibiotics decreased from 214 to 47 (P=0.02), and the number of chest X-ray confirmed infiltrates decreased from 20 to 6 (P=0.02) after injection. CONCLUSION In this review, there was a decrease in hospitalized days, antibiotic usage, and chest X-ray infiltrates after the salivary botulinum toxin injection. A prospective study is needed to evaluate whether this treatment can prevent aspiration pneumonia in neurologically impaired children.
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Affiliation(s)
- John Faria
- Department of Otolaryngology, State University of New York at Buffalo, 1237 Delaware Avenue, Buffalo, NY 14209, USA
| | - Jennifer Harb
- Department of Otolaryngology, State University of New York at Buffalo, 1237 Delaware Avenue, Buffalo, NY 14209, USA
| | - Aaron Hilton
- Department of Otolaryngology, State University of New York at Buffalo, 1237 Delaware Avenue, Buffalo, NY 14209, USA
| | - Dean Yacobucci
- Pediatric Interventional Radiology, Women and Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222, USA
| | - Michael Pizzuto
- Department of Otolaryngology, State University of New York at Buffalo, 1237 Delaware Avenue, Buffalo, NY 14209, USA.
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Hara H, Hori T, Sugahara K, Ikeda T, Kajimoto M, Yamashita H. Effectiveness of laryngotracheal separation in neurologically impaired pediatric patients. Acta Otolaryngol 2014; 134:626-30. [PMID: 24646141 DOI: 10.3109/00016489.2014.885119] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION Laryngotracheal separation (LTS) can prevent aspiration pneumonia, improve the respiratory condition, and offer the possibility of home care for neurologically impaired children. OBJECTIVES This study aimed to evaluate the effectiveness of LTS in neurologically impaired pediatric patients from the viewpoint of postoperative success of pneumonia prevention, improvement in the respiratory condition, and postoperative success rate of home-based care. METHODS The medical records of 21 children who underwent LTS at an academic medical center from September 2004 to March 2013 were retrospectively investigated. Pre- and postoperative data, including the frequency of pneumonia treatment, the frequency of sputum suctioning, the respiratory condition, the nutrition method, and the outcome after LTS were assessed. We also used the scoring system for patients with severe motor and intellectual disabilities, medical care dependent group (SMID-MCDG) in Japan for evaluating the usefulness of LTS. RESULTS The frequency of pneumonia treatment and that of suctioning decreased considerably after LTS. Furthermore, the respiratory condition improved at a rate of 63.19%. The SMID-MCDG score significantly reduced after LTS. No significant complications were observed and two-thirds of the patients were successfully discharged for home care after the procedure.
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Affiliation(s)
- Hirotaka Hara
- Department of Otolaryngology, Yamaguchi University Graduate School of Medicine , Ube, Yamaguchi
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Shino M, Yasuoka Y, Murata T, Ninomiya H, Takayasu Y, Takahashi K, Chikamatsu K. Improvement of tracheal flap method for laryngotracheal separation. Laryngoscope 2012; 123:440-5. [PMID: 23070689 DOI: 10.1002/lary.23632] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 06/25/2012] [Accepted: 07/09/2012] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Recurrent pneumonia due to intractable aspiration is a life-threatening disease. A tracheal flap method for children without previous tracheostomy has been previously reported. This study reports that improvements of this method and its three subtypes are widely applicable to patients with various conditions. STUDY DESIGN Surgical technique study. METHODS The tracheal flap method does not involve transection of the trachea but achieves laryngotracheal separation using the tracheal, mucoperichondrial, and sternohyoid muscle, along with anterior cervical skin flaps. This method can be divided into three subtypes as follows: A-type, utilizing the tracheal flap (for patients without previous tracheostomy); B-type, utilizing the mucoperichondrial and sternohyoid muscle flaps (for patients lacking an anterior tracheal wall); and C-type, utilizing the esophageal flap (for patients with severe hypersalivation). In all three subtypes, the anterior cervical skin flap is employed. RESULTS The tracheal flap method was performed in 30 patients (24 children and six adults) at risk of developing intractable aspiration pneumonia. In all 30 cases, aspiration pneumonia was prevented without severe complications. No fistula formation was observed. CONCLUSIONS All three subtypes (A-, B-, and C-type) of the tracheal flap method are effective in preventing the recurrence of aspiration pneumonia. This method is applicable to diverse patient backgrounds regardless of age or previous tracheostomy. It is less invasive than Lindeman procedure. Furthermore, this method is acceptable to patients' families and improves the QOL of both patients and caregivers.
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Affiliation(s)
- Masato Shino
- Department of Otolaryngology-Head and Neck Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
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8
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Suzuki H, Hiraki N, Murakami C, Suzuki S, Takada A, Ohbuchi T, Shibata M, Hashida K, Shimono M. Drainage of the tracheal blind pouch created by laryngotracheal separation. Eur Arch Otorhinolaryngol 2009; 266:1279-83. [PMID: 19283402 DOI: 10.1007/s00405-009-0942-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Accepted: 02/20/2009] [Indexed: 11/30/2022]
Abstract
Laryngotracheal separation is a simple and reliable operation for the treatment of patients with repetitive and intractable aspiration; however, it is apprehended that pooling in the tracheal blind pouch may cause postoperative complications. In the present study, we examined drainage of the blind pouch created by laryngotracheal separation. Fourteen patients aged 3-63 years with repetitive aspiration pneumonia underwent laryngotracheal separation by the modified Lindeman procedure. A barium swallow was performed 10-30 days after surgery. X-rays of the lateral view of the neck were taken at 6 and 24 h after the swallow, and then every 24 h until the contrast medium cleared. The contrast medium in the blind pouch cleared within 24 h in nine patients. In the remaining five, the clearance time was < or =48 and < or =72 h in two patients each, and 96 h in one patient. The clearance time in patients aged under 20 years was < or =24 h, while middle-aged to elderly patients showed prolonged clearance time. No late complications of the blind pouch, such as infections, were observed. The potential risk of complications caused by pooling in the tracheal blind pouch in laryngotracheal separation is prevented presumably due to the slow but continuous turnover of pooling material. This result supports the validity and usefulness of laryngotracheal separation for the treatment of intractable aspiration.
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Affiliation(s)
- Hideaki Suzuki
- Department of Otorhinolaryngology, University of Occupational and Environmental Health, Iseigaoka, Yahatanishi-ku, Kitakyushu, Japan.
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9
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Hamano K, Kumada S, Hayashi M, Uchiyama A, Kurihara E, Tamagawa K, Enomoto S, Chou H. Hemorrhage due to tracheoarterial fistula with severe motor and intellectual disability. Pediatr Int 2008; 50:337-40. [PMID: 18533948 DOI: 10.1111/j.1442-200x.2008.02573.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tracheoarterial fistula (TAF) is an unusual but highly lethal complication of tracheostomy, and successful surgical intervention for TAF has been reported. Few investigations are available for TAF in severe motor and intellectual disability (SMID). The aim of the present paper was to analyzed TAF in SMID to clarify which clinical variables might predict the occurrence of TAF, and adequate management for lifesaving. METHODS Medical records at Metropolitan Fuchu Medical Center were retrospectively investigated for SMID between 1970 and 2000, and 10 TAF patients verified on operation or autopsy were identified. Details were reviewed including clinical status, emergency treatment at the occurrence of TAF, and operation and/or autopsy recordings. RESULTS Four of 10 patients underwent successful operation and survived, while the other six died from hemorrhagic shock. Eight patients had tracheoinnominate artery fistula, the others had tracheocarotid artery fistula. Characteristic features as SMID such as etiology of brain disease, muscle tonus and convulsion were no apparent relevance to occurrence of TAF. All patients suffered from endotracheal granuloma extending to the arterial walls. Seven of 10 patients had re-bleeding after stabilization of the first massive hemorrhage, especially fiber bronchoscopy to confirm the diagnosis of TAF precipitated to fatal re-bleeding. One patient underwent interruption of the artery at relapse of TAF, the other three underwent suturing and had good outcome. CONCLUSIONS There were no apparent predictors of TAF in SMID. Tracheal granuloma was recognized and consequent on formation of TAF, so control of granuloma may prevent TAF. Fiber bronchoscopy for suspected TAF is not recommended because it precipitates fatal bleeding.
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Affiliation(s)
- Kimiko Hamano
- Department of Pediatrics, Tokyo Metropolitan Fuchu Medical Center for Disabled, Tokyo, Japan.
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10
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Hauer JM. Respiratory Symptom Management in a Child with Severe Neurologic Impairment. J Palliat Med 2007; 10:1201-7. [DOI: 10.1089/jpm.2007.9907] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Julie M. Hauer
- Department of Pediatrics, University of Minnesota, 717 Delaware Street SE, Minneapolis, MN 55414. E-mail:
- Gillette Children's Specialty Healthcare, St. Paul, Minnesota
- Children's Hospital Boston, Palliative Care Fellow, Boston, Massachusetts
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11
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Duke RL, Conley SF. Botulinum toxin as treatment for a unique case of subcutaneous emphysema. Int J Pediatr Otorhinolaryngol 2007; 71:353-6. [PMID: 17161470 DOI: 10.1016/j.ijporl.2006.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2006] [Revised: 10/24/2006] [Accepted: 10/29/2006] [Indexed: 10/23/2022]
Abstract
A developmentally delayed 11-year-old male developed extensive spontaneous subcutaneous emphysema 6 weeks after a laryngotracheal separation. Computed tomography demonstrated a small amount of air at the distal end of the laryngeal stump and significant esophageal air. Aerophagia was diagnosed with air presumed diverted through the laryngeal stump due to cricopharyngeal hypertension. Cricopharyngeal botulinum toxin injection was coordinated with a minimal neck dissection to drain the subcutaneous emphysema. The subcutaneous emphysema gradually improved and the patient was discharged home. His subcutaneous emphysema has not returned after four total botulinum toxin injections every 3 months.
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Affiliation(s)
- Rebecca L Duke
- Medical College of Wisconsin, Department of Otolaryngology and Communication Sciences, Milwaukee, WI 53226, USA
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12
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Manrique D, Settanni FAP, Camponês do Brasil ODO. Surgery for Aspiration: Analysis of Laryngotracheal Separation in 23 Children. Dysphagia 2007; 21:254-8. [PMID: 17216391 DOI: 10.1007/s00455-006-9048-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The aim of this study was to analyze the efficacy of laryngotracheal separation (LTS) in eliminating aspiration in children by comparing pre- and postoperative conditions. This prospective study used an internal control group. Children with neurologic impairment and a diagnosis of chronic aspiration were subjected to LTS at the Associação de Assistência à Criança Deficiente (AACD). Twenty-three children had undergone LTS with the modified Lindeman technique. All of them gained complete control of aspiration. Frequency of hospitalization, number of respiratory infections, and level of secretion were statistically reduced. After surgery only 21.7% of the children were capable of oral intake exclusively. LTS is an effective and safe technique that can be used in children resulting in aspiration control in 100% of the patients and without repercussions in the respiratory secretion and pulmonary infections.
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Affiliation(s)
- Dayse Manrique
- Department of Otorhinolaryngology, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.
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Hricko P, Storck C, Schmid S, Stoeckli SJ. Partial Cricotracheal Resection for Successful Reversal of Laryngotracheal Separation in Patients with Chronic Aspiration. Laryngoscope 2006; 116:786-90. [PMID: 16652088 DOI: 10.1097/01.mlg.0000206130.32458.71] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To present our experience with successful reversal of laryngotracheal separation in patients with chronic aspiration, to discuss our surgical technique, and to review the literature. STUDY DESIGN Retrospective case review. METHODS The medical records of two patients who underwent a successful reversal of laryngotracheal reversal after separation were reviewed. The two patients were evaluated clinically with videostroboscopy and videofluoroscopy. RESULTS Both patients presented with intractable aspiration despite protective tracheostomy because of impairment of lower cranial nerve function. After laryngotracheal separation, swallowing rehabilitation was safely possible, and neurologic improvement allowed reversal of the separation procedure. For reversal, we present the use of a partial cricotracheal resection with tracheocricothyropexia similar to the technique used for subglottic stenosis. Both patients were successfully reversed. Satisfactory voice and swallowing function 7 and 10 years after reversal, respectively, could be assessed through our evaluation. Review of the literature revealed a total of 13 cases of successful reversal after laryngotracheal separation. Technical details of surgery and functional results are rarely reported.
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Affiliation(s)
- Peter Hricko
- Clinic of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Switzerland
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14
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Hamano K, Kumada S, Hayashi M, Naito R, Hayashida T, Uchiyama A, Kurata K. Laryngeal dystonia in a case of severe motor and intellectual disabilities due to Japanese encephalitis sequelae. Brain Dev 2004; 26:335-8. [PMID: 15165675 DOI: 10.1016/s0387-7604(03)00194-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2003] [Revised: 10/06/2003] [Accepted: 10/06/2003] [Indexed: 11/29/2022]
Abstract
Laryngeal dystonia is characterized by stridor due to vocal cord dystonia and is observed in extrapyramidal disorders. Recently, botulinum toxin injection has been used as a primary therapy. Generally, severe motor and intellectual disabilities (SMID) are frequently complicated by various types of respiratory disorders. We report a SMID case with Japanese encephalitis sequelae showing repeated vocal cord abductor disturbance due to laryngeal dystonia, in addition to generalized dystonia, in whom MRI revealed basal ganglia lesions. Tracheostomy was effective for the case, and we believe that botulinum toxin injection may be inappropriate in SMID, both ethically and technically. Also, laryngeal dystonia should be considered as a cause of respiratory disorders in SMID.
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Affiliation(s)
- Kimiko Hamano
- Department of Pediatrics, Metropolitan Fuchu Medical Center for Severe Motor and Intellectual Disabilities, 2-9-2 Musashidai, Fuchu-shi, Tokyo 183-0042, Japan.
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15
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Abstract
Fundoplication is the standard surgical approach to gastroesophageal reflux (GER) in a child. Although successful in many patients, there is a significant risk of complications and failure, especially in high-risk patients such as those with certain types of associated anomalies, diffuse motility disorders, chronic pulmonary disease, neurologic impairment, and young infants. Fundoplication failure can take the form of persistent reflux-related symptoms, symptoms that are caused by complications of the surgery, or anatomic problems such a para-esophageal hernia or migration of the wrap into the mediastinum. The most effective strategy for treatment of the child undergoing fundoplication is to prevent failure by careful patient selection, individualization of the operation based on the patient's anatomy and physiology, and meticulous attention to the technical details of the operation. Options for the child with a failed fundoplication include medical management, jejunal feeding using a percutaneous tube or a Roux-en-Y jejunostomy, revision of the fundoplication, or esophagogastric dissociation. If the fundoplication is to be revised, the same principles of patient selection, individualization of the operation, and attention to technique must be used to optimize the chance of success. The primary goal in the treatment of GER is to improve quality of life for the patient and the family.
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Affiliation(s)
- Jacob C Langer
- University of Toronto, Department of Pediatric General Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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Abstract
Introdução: Quando o mecanismo protetor da laringe está comprometido, o paciente pode apresentar aspiração traqueal, com graves complicações pulmonares. Objetivo: Relatar 15 casos de tratamento cirúrgico para o controle da aspiração crônica, incluindo as técnicas cirúrgicas empregadas, seus resultados e complicações. Forma de estudo: Avaliação retrospectiva. Material e método: No período de 1997 a 2000, 15 pacientes foram submetidos à cirurgia para controle da aspiração, na AACD - São Paulo/SP. As técnicas cirúrgicas empregadas foram classificadas em: oclusão laríngea supraglótica; oclusão laríngea glótica; oclusão subglótica ou separação laringotraqueal. Foi avaliado o perfil dos pacientes em relação a sexo, idade, etiologia de base, traqueotomia prévia, via preferencial de alimentação, redução das infecções pulmonares, tempo de seguimento pós-operatório e complicações. Resultados: Oito pacientes eram do sexo masculino e sete do feminino, com idade média de nove anos e dois meses. A doença etiológica de base mais comum foi a encefalopatia crônica. Dez pacientes foram submetidos à traqueotomia previamente à cirurgia. Nove pacientes apresentaram, no pós-operatório, dieta via oral de pelo menos 50% do volume requerido. Os 15 pacientes evoluíram com diminuição no número e na gravidade das infecções pulmonares. O tempo de seguimento pós-operatório variou de quatro a 36 meses. Um paciente evoluiu com deiscência parcial na técnica de oclusão laríngea supraglótica. Conclusão: A cirurgia para controle da aspiração traqueal, nas três técnicas utilizadas, foi eficaz para prevenção da aspiração, refletindo na melhora clínica e na qualidade de vida dos pacientes.
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Affiliation(s)
- Dayse Manrique
- Universidade Federal de São Paulo - Escola Paulista de Medicina; Hospital do Servidor Público Estadual - Francisco Morato de Oliveira; AACD
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Finder JD, Yellon R, Charron M. Successful management of tracheotomized patients with chronic saliva aspiration by use of constant positive airway pressure. Pediatrics 2001; 107:1343-5. [PMID: 11389254 DOI: 10.1542/peds.107.6.1343] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Management of chronic aspiration of saliva is a challenge to clinicians. The purpose of this report is to review the clinical course of 3 patients with tracheotomy who we have followed for at least 1 year and who have received constant positive airway pressure (CPAP) as a primary treatment for ongoing aspiration of saliva. METHODS Retrospective chart review. RESULTS We present here 3 patients with chronic congestion and persistent hypoxemia in whom a diagnosis of chronic aspiration of saliva was established by use of radionuclide salivagram. Each of these children had tracheotomy for treatment of airway obstruction. In an attempt to decrease chronic aspiration of saliva, we instituted constant positive pressure via tracheotomy. Repeat radionuclide salivagram performed on CPAP demonstrated a marked decrease in saliva aspiration. All patients experienced improvement in clinical symptoms and required only rare subsequent hospitalizations for respiratory disease. CONCLUSION We suggest, based on this case series, that CPAP administered via a tracheotomy is an acceptable means of managing chronic salivary aspiration and that it may decrease respiratory complications in such patients.
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Affiliation(s)
- J D Finder
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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