Surgical Management of Chronic Aspiration

What Is Chronic Aspiration?

Chronic aspiration is a condition where swallowed food and liquid enters the larynx (windpipe) instead of the esophagus (food pipe) repeatedly. It is a complication of an underlying disease rather than a disease itself. Occasionally aspiration happens to everyone, followed by a rapid cough to get rid of the aspirated substances, but in chronic aspiration, the food and liquid that enter the lungs through the windpipe do not get expelled.

This causes inflammation and infection of the lungs and, if untreated, can lead to serious complications, including death. It is commonly seen in children, the elderly, and intubated patients.

Is Chronic Aspiration Same as Choking?

The differences between choking and aspiration are mentioned below-

Who Are Affected With Chronic Aspiration?

Any impairment that causes difficulty in speaking, swallowing, or breathing also causes chronic aspiration. It is often seen in children and the elderly due to their susceptibility to neuromuscular disorders; however, chronically intubated patients, irrespective of age, also can suffer from chronic aspiration.

Swallowing is a three-step process

a) Oral phase.

b) Pharyngeal phase.

c) Esophageal phase.

Except for the oral phase, the rest of the two phases are involuntary in nature. Any defects in these phases cause aspiration. Following are the different conditions that cause chronic aspiration-

• Neuromuscular Disorders: Swallowing is a complex motor activity that involves the brain that sends the signals, the nerves that transport the signals, and the muscles that actually perform the act of swallowing. Any diseases that affect the brain, nerves, and muscles cause dysphagia (difficulty in swallowing) which will lead to aspiration.

Not all of the above-mentioned diseases affect swallowing in the same way; for example- patients with Parkinson’s have muscle weakness due to neurologic decline; in cerebral palsy patients, the difficulty in swallowing arises due to decreased oral secretions, and defects in cranial nerve Ⅴ, Ⅹ, and Ⅸ reduce the cough reflexes which are essential to prevent food from entering the larynx thereby facilitating aspiration.

• Pulmonary Disease: Critically ill patients who are on ventilators and patients suffering from chronic kidney disease, heart failure, and chronic obstructive pulmonary disease have poor forced expiratory volume, which leads to weak respiratory and laryngeal musculature and increased risk for aspiration.

• Supraglottic Disease: Supraglottis is the uppermost part of the larynx; it contains epiglottis- the cartilage that acts as a lid to prevent food from entering the larynx (windpipe). Any defects in the supraglottis lead to aspiration, for example- laryngomalacia, Zenker’s diverticulum, achalasia, etc.

All the conditions mentioned above explain aspiration from a defective swallowing point of view, but reflux is one of the less-represented causes of aspiration. It happens once the food has been swallowed, usually due to impaired functioning of the lower esophageal sphincter.

What Are the Symptoms of Chronic Aspiration?

The following are the symptoms of aspiration caused due to dysphagia-

• Coughing, wheezing, and gagging while eating.

• Feeling like something is stuck in the throat.

• Chest congestion and difficulty in breathing during and after eating.

• Fever after 30 minutes of eating anything.

• Vomiting after meals.

• Repeated episodes of pneumonia.

• Trouble starting a swallow and excess drooling.

Occasionally a few individuals who aspirate do not have any symptoms; this is known as silent aspiration.

How Is Chronic Aspiration Diagnosed?

Along with symptoms and a physical exam, the clinician will ask for complete medical history, followed by an evaluation by a speech-language pathologist. This will help with the initial diagnosis; the clinician will then order some tests to reach a definitive diagnosis; they are-

• The modified barium swallow (MBS) test allows seeing the aspirated food in the lungs.

• Fiber-optic endoscopic evaluation of swallowing (FEES)- An endoscope (illuminated tube with a camera) helps to take pictures when the patient is swallowing food and liquids.

• Bronchoscopy is similar to FEES, but instead of the nose, the clinician will insert a bronchoscope through the mouth.

• Pharyngeal manometry helps to measure the pressure changes in the throat while swallowing by using a catheter-containing sensors.

How Is Chronic Aspiration Treated?

The first step to managing chronic aspiration is always conservative treatment, failure of which will need surgical intervention.

1. Conservative Treatment: This involves addressing the underlying causes of speech and swallow abnormalities, often with the help of an otolaryngologist, a gastroenterologist, a speech therapist, a psychiatrist, a radiologist, and neurosurgeons.

The medication part of the treatment comprises antiemetics, H2 antagonists, and proton pump inhibitors. If pathological pneumonia is seen, then broad-spectrum antibiotics are also prescribed. Studies have shown that feeding and swallowing therapy resolved to swallow dysfunction in almost 80% of individuals.

2. Surgical Treatment: Depending on the underlying condition, the surgeon may choose any one of the following approaches which are as follows:

• Tracheostomy: Used for patients who need a longer duration of mechanical airway support and upper respiratory tract obstruction. Tracheostomy itself has a high risk of aspiration, but this is one of the situations where the pros outweigh the cons.

A hole (tracheal stoma) is made through the front of the neck and extended into the trachea; a tracheal tube is inserted through the hole to keep it open during breathing. Post-surgical instructions include tracheostomy care and cleaning.

Note: Tracheostomy is a permanent opening of the trachea by creating a hole (tracheal stoma), whereas tracheotomy is a temporary opening of the trachea created by a small incision. Both procedures are followed by the placement of a tracheal tube to facilitate breathing.

• Laryngectomy:

  • Reserved for life-threatening conditions like head and neck cancers. The procedure removes the entire or part of the larynx, which takes away the patient’s ability to speak permanently.

  • The surgeon makes an incision in the neck, which gives access to the underlying larynx; depending on the type of cancer, a part or complete larynx will be removed. At this point, the surgeon will perform a tracheostomy (creation of tracheal stoma and placement of tracheal tube).

  • It is a life-altering procedure after which the patient will have to learn how to breathe, swallow, and communicate.

• Total and Partial Cricoid Resection: Often done in subepiglottic stenosis, which causes narrowing at the level of the cricoid cartilage. In cricoid resection, the narrowed part is removed, and the larynx and trachea are sewn back together.

• Laryngeal Closures:

  • This is done in patients suffering from recurrent aspiration pneumonia (pneumonia caused due to repeated aspiration). It is a life-threatening condition that needs immediate attention.

  • The larynx automatically closes during swallowing in a healthy individual; it occurs by approximation of epiglottis to the underlying cartilage.

  • In patients with recurrent aspiration pneumonia, this automatic closure of the epiglottis does not occur, and food repeatedly enters the larynx to prevent this laryngeal closure.

  • An incision is placed in the neck, and the underlying central thyroid is removed; the next two flaps (superior and inferior) are created out of the vocal folds present in the larynx.

  • These flaps are elevated and attached to the larynx with the help of sutures, resembling a valve that does not open. This is followed by a tracheostomy to help the patient breathe.

A few additional surgeries available for people suffering from chronic aspiration are tracheoesophageal diversion, laryngeal suspension, vocal fold medialization, and adjunctive procedures. The type of surgery depends on the underlying condition and is decided by the surgeon after careful evaluation.

What Are the Complications of Surgery for Chronic Aspiration?

At this point, it is established that any surgery for chronic aspiration is not elective, it is only done to save the life of the patient, and the patients who receive the procedure themselves are extremely frail. The complications of the procedures are-

• Bleeding and hematoma.

• Tracheostomy tube plugging and accidental decannulation.

• Infection and fistula formation.

• Airway obstruction and dysphonia.

Patients should receive adequate care post-surgery, including tracheostomy care, postoperative antibiotics, and wound care which minimizes the chances of complications.

Conclusion:

Chronic aspiration is a well-researched pathology with well-established treatment standards. Treatment involves a multi-disciplinary approach and should always be focused on the prevention of aspiration rather than curing it. If it does occur, a conservative approach should always be the first choice, followed by surgery. Successful implementation of either treatment depends on long-term management to prevent relapse.