Aspiration prevention surgeries: a review

Vocal Fold Motion Impairment in Neurodegenerative Diseases

Vocal fold motion impairment (VFMI) is the inappropriate movement of the vocal folds during respiration, leading to vocal fold adduction and/or abduction problems and causing respiratory and vocal impairments. Neurodegenerative diseases (NDDs) are a wide range of disorders characterized by progressive loss of neurons and deposition of altered proteins in the brain and peripheral organs. VFMI may be unrecognized in patients with NDDs. VFMI in NDDs is caused by the following: laryngeal muscle weakness due to muscular atrophy, caused by brainstem and motor neuron degeneration in amyotrophic lateral sclerosis; hyperactivity of laryngeal adductors in Parkinson's disease; and varying degrees of laryngeal adductor hypertonia and abductor paralysis in multiple system atrophy. Management of VFMI depends on whether there is a presence of glottic insufficiency or insufficient glottic opening with/without severe dysphagia. VFMI treatment options for glottic insufficiency range from surgical interventions, including injection laryngoplasty and medialization thyroplasty, to behavioral therapies; for insufficient glottic opening, various options are available based on the severity and underlying cause of the condition, including continuous positive airway pressure therapy, botulinum toxin injection, tracheostomy, vocal fold surgery, or a combination of interventions. In this review, we outline the mechanisms, clinical features, and management of VFMI in NDDs and provide a guide for physicians who may encounter these clinical features in their patients. NDDs are always progressive; hence, timely evaluation, proper diagnosis, and appropriate management of the patient will greatly affect their vocal, respiratory, and swallowing functions as well as their quality of life.

Total Laryngectomy for Respiratory Complications From Advanced Duchenne Muscular Dystrophy

Due to respiratory weakness, late-stage Duchenne muscular dystrophy (DMD) patients may suffer from chronic aspiration, which is sometimes treated using tracheostomy. However, definitive laryngectomy has not been described in the literature as an aspiration prevention modality in DMD, especially in patients with contraindications to tracheostomy. A case is presented for a patient with advanced stage Duchenne muscular dystrophy suffering from chronic aspiration pneumonia and excessive oral secretions who became ventilator dependent. A tracheostomy was placed, but was noted to have excessive secretions and high cuff pressures, which have been known to be associated with worsened swallow dysfunction as well as tracheoinnominate fistula. The patient therefore was considered for total laryngectomy, which he underwent successfully. Post-operatively, the patient was noted to have improved subjective quality of life, engaged in an oral diet, and had less secretions surrounding his tracheostoma post-operatively. Aspiration prevention surgeries are done to improve quality of life by improving oral intake, decreasing the need for frequent suctioning, and can sometimes allow for speech. It is important to consider quality of life for DMD patients as more of these patients are living into their 30s with the aid of mechanical ventilation. Laryngectomy is a surgery that can definitively correct chronic aspiration while allowing for oral intake. Laryngoscope, 2024.

Management and Treatment for Dysphagia in Neurodegenerative Disorders

Patients with neurodegenerative disorders (NDDs) often experience functional dysphagia, which may involve dysfunction in a specific phase of swallowing or in the entire process. This review outlines the approach to dysphagia in the setting of NDDs. Distinguishing the etiology of dysphagia can be difficult, and it is important to always look out for signs pointing to NDD as the cause. Thorough diagnostic work-up is essential, and it includes a comprehensive history and physical examination, alongside swallowing function tests, such as fiberoptic endoscopic evaluation of swallowing, videofluoroscopic swallowing study, and high-resolution manometry. Management requires a multidisciplinary approach with a treatment plan tailored to each patient. This involves dietary guidance, swallowing rehabilitation, and surgery in cases in which improvement with rehabilitation is inadequate. Surgery may involve altering certain pharyngolaryngeal structures to facilitate swallowing and reduce the risk of aspiration (swallowing improvement surgery) or separating the airway and digestive tract while sacrificing laryngeal function, with the main goal of preventing aspiration (aspiration prevention surgery). Proper management stems from recognizing the impact of these disorders on swallowing and consistently finding ways to improve the quality of life of patients.

Clinical Significance of Surgical Intervention to Restore Swallowing Function for Sustained Severe Dysphagia

Owing to rapid population aging, patients with dysphagia are significantly increasing in society. Dysphagia treatment is aimed at the restoration of the swallowing function and the prevention of recurrent aspiration-induced pulmonary infection. However, despite intensive rehabilitation, oral food intake remains inadequate in many patients with severe dysphagia, which results in the deterioration of patients' quality of life and joy of living. Surgical intervention may serve as a useful therapeutic strategy to restore swallowing function in these patients. The study included 25 patients (mean, 70.4 years; male/female ratio, 20:5) with chronic dysphagia. Dysphagia was associated with cerebrovascular diseases in sixteen patients; with age-induced physiological deterioration in five patients; and with miscellaneous etiologies in four cases. Cricopharyngeal and infrahyoid myotomies were performed in all patients. Laryngeal elevation and the medialization of the paralyzed vocal fold were performed in 15 and 3 patients, respectively. The Food Intake Level Scale (FILS) and videoendoscopic examination score (VEES) were used to evaluate swallowing function. The FILS showed a restoration of oral food intake alone in 72% of patients, and 64% of patients maintained this improvement at their last follow-up visit. We observed significantly improved VEES scores postoperatively. However, patients with cognitive impairment or advanced age showed poor outcomes. In conclusion, surgical intervention may be an effective therapeutic option to restore swallowing function in cases of sustained severe dysphagia; however, surgical indications require careful consideration.