LARYNGECTOMY FOR ASPIRATION:

NARROW FIELD TECHNIQUE

YOSEF P. KRESPI, MD, ANDREW BLITZER, MD, DDS

Patients with intractable aspiration present formidable management difficulties. Many surgical solutions have been
devised. In cases in which there is life-threatening aspiration and no prospect of reversal of the underlying pathology,
we use narrow-field laryngectomy to prevent aspiration-associated pleuropulmonary infections. The surgical
technique comprises sparing of strap muscles, a high tracheal transection, and conserving a maximum amount of
pharyngeal mucosa, so that the pharyngeal opening is quite small and may be closed rapidly. We have used this
approach successfully in 10 patients. Narrow-field laryngectomy has proven to be a safe, efficacious technique for the
management of persistent aspiration in these gravely ill patients.

Aspiration pneumonia is the frequent fate of many from the bacteria in oral secretions and the chemical
patients with motor neurone disease. Neurologists are content and pH of the aspirated material. Aspirated food
often faced with a case in which the symptoms are particles or a thick transudate leads to bronchial obstruc-
predominantly bulbar. In such cases, the quality and tion, atelectasis, and lung abscess.
quantity of life may be dramatically improved if the Aspiration of material into the tracheobronchial tree
aspiration can be prevented. represents a triple threat 2 of chemical pneumonitis, bacte-
Severe and permanent dysphagia with aspiration may rial pneumonia, and mechanical obstruction of the air-
arise in patients with vascular accidents involving the ways.
brain-stem, poliomyelitis, myasthenia gravis, pseudobul- Aspiration of oropharyngeal material containing large
bar palsy, motor-neurone disease, head trauma posterior numbers of bacteria produces, by definition, aspiration-
fossa surgery, lye burns of the aerodigestive tract, and associated pleuropulmonary infections. Aspiration-associ-
other neurological conditions. ated pleuropulmonary infection usually manifests itself as
Once the ambulant patient with motor neurone disease a more indolent disease than gastric acid aspiration. 3
has reached the stage of aphonia with severe aspiration Cultures of saliva yield about l0 s bacteria/mL, with
with or without a tracheotomy, then surgery should be anaerobic bacteria predominating over aerobic and faculta-
offered to relieve his / her distress. Management by narrow- tive organisms in a ratio of up to 10 to 1.2 Thus, anaerobic
field laryngectomy offers an effective treatment by a single bacteria account for most of the pleuropulmonary infec-
surgical procedure with a short hospital stay. tions due to aspiration in nonhospitalized patients. 3-5
If, after an interval of some weeks or months, recovery is Clinical manifestations of aspiration-associated pleuro-
not sufficient and is not likely to improve or the patient's pulmonary infections comprise a spectrum from mini-
condition has deteriorated, there are grounds for consider- mally symptomatic pneumonia to necrotizing lung infec-
ing laryngectomy as a course of treatment that will remove
tions, abscess formation, and empyema. The clinical
the dangers of recurrent aspiration pneumonia. If dyspha-
presentation of this infection includes typical symptoms of
gia is permanent and severe, total laryngectomy may
cough, sputum production, fever, pleuritic chest pain,
provide a means of ensuring that the contents of the
night sweats, and weight loss? Symptoms of anaerobic
alimentary tract can in no circumstances enter the airway.
Patients who have severe and permanent dysphagia may pleuropulmonary infection (especially lung abscess and
die from pneumonia unless adequate precautions are empyema) are often indolent and have been mistaken for
taken to prevent inhalation of food and secretions. Total tuberculosis or bronchogenic carcinoma. 5
laryngectomy, by separating the airway from the food Drainage of infected material in the case of simple
passages, prevents inhalation permanently and com- pneumonia or necrotizing pneumonia is readily accom-
pletely, and may permit the patient to return home to a plished by patient coughing and judicious chest physical
relatively normal life? therapy with postural drainage. Percutaneous drainage of
The incompetent larynx is usually manifested by aspira- lung abscess 6 and lobectomy 7 may be of benefit in those
tion, which may lead to anything from a minor irritating rare cases that fail to improve with medical therapy alone.
cough to a life-threatening pneumonia. Aspiration pneumo- Prevention of recurrent aspiration-associated pleuropul-
nia results from the overflow of saliva or food into the monary infections is predicated upon the prevention or
distal tracheobronchial tree. The damage produced results reversal of the underlying dysfunction causing aspiration.
Patients with neurological and neuromuscular disease
who develop recurrent and severe aspiration-associated
pleuropulmonary infections due to laryngeal incompe-
From the Department of Otolaryngology, Head and Neck Surgery, St.
tence are a very challenging group. The propriety of
Luke's/Roosevelt Hospital, New York, NY.
Address reprint requests to Yosef P. Krespi, MD, 425 W 59th St, Ste 4E, surgical correction for this debilitating problem rests upon
New York, NY 10019. the quality of the patient's life and prospects for survival
Copyright © 1997 by W.B. Saunders Company after therapy. Most of these techniques result in the
1043-1810/97/0804-0007505.00/0 permanent or temporary loss of speech, which may not be

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 8, NO 4 (DEC), 1997: PP 227-230 227
acceptable to some patients under any circumstances.
Initial surgical procedures for the prevention of aspiration
usually consist of tracheostomy with a cuffed tube and
&&
creation of a feeding gastrostomy or jejunostomy. More
effective surgical procedures are based on the anatomic
isolation of lower airway from pharynx and consist of
laryngotracheal closure procedures, laryngeal diversion
procedures, and total laryngectomy. ~
In evaluating the patient with an incompetent larynx
and severe aspiration, several factors must be considered:
(1) the likelihood for recovery of laryngopharyngeal func-
tion; (2) general condition of the patient, including meta-
bolic and nutritional status as well as the presence of other
systemic conditions; (3) the potential for reversibility of the
aspiration with skilled nursing care; and (4) alleviation of
aspiration pneumonitis with pulmonary toilet and appro-
priate antibiotic therapy. For those patients for w h o m the i
prognosis for rehabilitation or long-term survival is poor,
and those who have other associated medical problems, or
are likely to have poor w o u n d healing, laryngectomy
should be the procedure of choice. This approach removes

S
the source of the aspiration and prevents further insult to
the tracheobronchial tree. The patient is also spared numer-
ous, partially successful surgical procedures and the dan-
ger of continued aspiration.

SURGICAL TECHNIQUE
The patient is placed on the operating table on supine
position with the neck slightly extended. Because most FIGURE 1. Vertical incision above the tracheostoma extending
patients with chronic aspiration may not be suitable to the level of the hyoid bone.
candidates for general anesthesia, the procedure can be
performed under local anesthesia using 1% xylocaine with women in this group. All patients had preexisting tracheos-
1/100,000 epinephrine and intravenous sedation. Because tomies to provide puhnonary toilet and treat persistent
all patients have preexisting tracheostomies, a vertical aspiration and aspiration-related pleuropulmonary infec-
incision from the upper end of the tracheostomy site to tions. Four patients were using nasogastric feeding and six
hyoid bone is performed. We have found that limited patients were fed via gastrostomy tube. Two of the 10
elevation of neck flaps laterally and the vertical incision patients were receiving additional nutrition via parenteral
provides a safe w o u n d in these debilitating patients. The hyperalimentation at the time of the laryngectomy. Most of
incision is carried to the level of the strap muscles in the the patients underwent one or more surgical procedures to
midline. The strap muscles are elevated off the laryngeal prevent aspiration. Six patients had Teflon a n d / o r Gel-
framework to expose the thyroid and cricoid cartilages. A
self-retaining retractor placed deep to the strap muscles
exposes the larynx and the upper trachea. A permanent
tracheostoma is formed at the level of first or second
tracheal ring. The cricoid is then lifted upward and
separated from the postcricoid mucosa. Every attempt is
made to preserve as much postcricoid mucosa as possible.
The pharynx is entered at the level of the arytenoid
cartilages. A limited infrahyoid pharyngotomy is per-
formed to expose the epiglottis. Most of the pharyngeal
mucosa at the postcricoid area, aryepiglottis folds and the
vallecula are preserved, thereby limiting the size of the
pharyngeal opening. The pharynx is closed with nonabsorb-
able sutures, and this sutureline is supported with the
strap muscles as a second layer. A permanent tracheostoma
is formed in the usual manner. The w o u n d is dosed in
layers and drained with a small penrose drain. The patient
is fed via nasogastric tube for 5 to 10 days until they are
ready for oral feedings (Figs 1 through 4).

SURGICAL EXPERIENCE
Ten patients with various end-stage neurological disorders
underwent narrow-field laryngectomy for persistent aspi-
ration in two different university hospitals. Ages varied FIGURE 2. Exposure of the laryngeal framework by retracting
from 11 to 75 years. There were seven men and three the strap muscles.

228 LARYNGECTOMY FOR ASPIRATION

 J vocal cords with autologenous cartilage grafts might be
more appropriate. 13
Laryngeal closure procedures can be performed at the
glottic or supraglottic level. Montgomery 14 described clo-
sure of the vocal cords via median thyrotomy. Sasaki is
interposed a muscle flap above the vocal cord closure to
provide a better glottic seal. Haba116 published a horizontal
closure of the supraglottis in two layers. Biller17 described
vertical supraglottic closure. In general, laryngeal closure
procedures do not provide complete protection of the
lower airway. It is our opinion that this step can be
eliminated in the management of patients with an end-
stage neurological condition and chronic aspiration. Pa-
tients with recurrent aspiration-associated pleuropulmo-
nary infections that failed glottic prosthesis or vocal cord
augmentation must be considered candidates for tracheo-
esophageal diversion or narrow-field laryngectomy.
Tracheoesophageal diversion, as described by Linde-
man, is provides a complete separation of the air and food
passages in a reversible fashion. Because most, if not all, of
the patients have preexisting tracheostomies, modifica-
tions of tracheoesophageal diversion have been de-
scribed. 19,2°In general, tracheoesophageal diversion can be
technically demanding, and may prolong the surgical
procedure and hospital stay in these very ill patients.
Cannon 21 managed four patients with severe intractable
aspiration by total laryngectomy and concluded that,
when the prognosis for recovery of laryngeal function is
poor, or when wound healing is compromised, a laryngec-
FIGURE 3. Permanent tracheostoma is placed at the level of tomy is the procedure of choice.
first tracheal ring. The cricoid is pulled upwards and most of the Narrow-field laryngectomy is a simple and reliable
postcricoid mucosa is preserved. Pharynx is entered along the treatment for chronic severe aspiration in patients with
arytenoid mucosa. motor neurone disease. The procedure can be performed
under local anesthesia rapidly when necessary. Unlike a
total laryngectomy performed for cancer, the strap muscles
foam injections (Upjohn Co., Kalamazoo, MI) into their are preserved and are used during the closure to reinforce
vocal cords. Two patients had cartilage implant for augmen-
tation of their vocal cords. Two patients underwent crico-
pharyngeal myotomy. One patient underwent vocal cord
closure that failed to completely protect the lower airway.
All patients were treated for at least two episodes of
aspiration-related pleuropulmonary infections.
All patients tolerated the narrow-field laryngectomy

I J
well. In the majority of the patients, the procedure was
performed under local anesthesia with sedation. Pharyn-
geal fistula was not detected in any of the patients. Patients
were fed 5 to 11 days after the laryngectomy and were
discharged from the hospital shortly after that.

DISCUSSION
The otolaryngologist consulting the patient with chronic
persistent aspiration who has a tracheostomy and gastros-
tomy tubes in place may consider the following measures ._J
before recommending total laryngectomy: (1) glottic pros-
thesis, (2) augmentation of the vocal cords, (3) glottic or
supraglottic laryngeal closure, and (4) tracheoesophageal
diversion. All of these procedures are potentially reversible
in the restoration of voice.
A variety of glottic prosthesis have been described in the
literature. 9 However, the most effective and physiological
prosthesis appears to be the one that was popularized by
Eliachar. 1° This laryngeal prosthesis allows phonation, and
it is made of soft silicone. The prosthesis can be easily
inserted through the tracheostomy site.
Augmentation of the vocal cords is usually performed
via transoral n or transcutaneous-transtrachea112 injection
of Teflon or Gelfoam. In larger defects, augmentation of the FIGURE 4. Closure of small pharyngeal opening.

KRESPI AND BLITZER 229

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230 LARYNGECTOMY FOR ASPIRATION