Abstract
A procedure for laryngotracheal separation was performed on 5 elderly patients in poor general condition to prevent habitual aspiration pneumonia. Intractable aspiration was relieved in all the patients with no major postoperative complications. In this intervention, a modification of the procedure previously reported, the anterior part of the tracheal and cricoid cartilage was removed, and the subglottic mucosa was sutured to fashion a blind pouch. This procedure could be adjusted even in cases of severe laryngoptosis or after high tracheostomy. Laryngotracheal separation is likely to be useful as a simple and safe procedure even for older patients. If this comes to be, it will serve as a valuable intervention in today’s aging society.
1
Introduction
The incidence of dysphagia and ensuing aspiration pneumonia has recently been increasing in the elderly . The management of aspiration is likely to grow in importance as society ages. Interventions to manage the condition will become more common, and the incidence of problems will increase. Some patients have the problem temporarily, whereas others are burdened for life. Some patients require only swallowing training with specific diet modifications to improve the function, whereas others are sadly forced to forego oral intake or even submit to surgery. Total laryngectomy should sometimes be considered as a final solution for the prevention of habitual aspiration pneumonia in elderly patients . Yet surgeons often hesitate to perform total laryngectomy in elderly patients, especially when a poor general condition of the patient or inadequate nutrition poses a risk of postoperative complications such as anastomotic leak. To address this problem, we decided to develop a laryngotracheal separation procedure for elderly patients by referring to the previous report. To our knowledge, this is the first report to describe a series of laryngotracheal separation interventions for elderly patients.
2
A report on 5 cases
From July 2008 to September 2009, 5 Japanese patients underwent laryngotracheal separation procedures for intractable aspiration at Tokyo Metropolitan Fuchu Hospital, Tokyo, Japan. The patients were 4 men and 1 woman with a mean age of 78 years (range, 73–83 years). Of the 5 patients, 4 had intractable aspiration pneumonia after brain infarction, and one had the condition after a convulsive-seizure-induced encephalopathy. Tracheostomy and cannulation with a cuffed tube had already been performed on 3 of the 5 patients. All 5 of the patients had lost speech function and gave their informed consent for deprivation of laryngeal function. We opted for a procedure less invasive than total laryngectomy, as every patient had other complications with the potential to delay wound healing, such as malnutrition, diabetes mellitus, or gastroesophageal reflux disease. The operations were performed under general anesthesia. In the very similar intervention for pediatrics reported by Ninomiya et al , the laryngotracheal structure is separated, and a permanent tracheal stoma is formed with a U-shaped skin flap without peeling off the tracheal posterior wall from the esophagus. In our procedure, a modification of the aforesaid, we removed the anterior part of the first/second tracheal cartilage and cricoid cartilage after exteriorizing the cartilages by amputation of the thyroid isthmus and removal of the cricothyroid muscles, then peeled off the laryngotracheal mucosa cylindrically ( Fig. 1 A ) and sutured it to make a mucosal subglottic blind pouch ( Fig. 1 B). When we encountered difficulty in detaching the tracheal cartilage, we managed subglottic closure by detaching only the cricoid cartilage and exfoliating the subglottic mucosa upwardly. The final step of the operation was to form a permanent tracheal stoma with a skin flap to overlie the subglottic mucosal pouch ( Fig. 1 C).
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