“Gold standard” surgical procedure for prevention of aspiration is:
Correct Answer: Tracheal division and permanent tracheostome
Description: Aspiration is the passage of foreign material beyond the vocal cords: The larynx has 3 distinct functions - respiration, phonation and airway protection. Dysfunction of larynx can lead to aspiration. The primary goal of treatment of aspiration is to separate the upper digestive tract from the upper respiratory tract for a sho period of time or in some cases, permanently. There are 3 broad categories of treatment. Temporary/Adjunct Treatments Medical Therapy - in the form of antibiotics is impoant to prevent aspiration pneumonia. It is impoant to make the patient NPO, to avoid fuher aspiration and to find an alternate feeding route to maintain the patients nutritional status. A nasogastric tube (feeding gastostomy/jejunostomy) is commonly placed, but this may actually increase the aspiration reflux by making the lower esophageal and upper esophageal sphincters incompetent. Vocal cord medialization (by injecting Gel foam) is useful in unilateral paralysis.This is helpful but is rarely curative, if there is a serious aspiration problem. Tracheostomy will often make aspiration worse by preventing laryngeal elevation on swallowing. It does however, allow easy access to the chest for suctioning. Even a cuffed tube doesn't prevent aspiration as secretions pool above the cuff and the seal is never perfect"- Scotts Brown 7th/ed vol 1 pg. 1278 Definite - Reversible Procedures Endolaryngeal stents: They function like a cork in the bottle. There job is to seal the glottis and therefore thay need to be used in conjunction with a tracheostomy tube. But they are not often used as they are effective only as a sho term solution, plus there is risk of glottic stenosis. Laryngotracheal separation: The procedure involves transecting the cervical trachea and bringing out the lower end as a permanent end stoma But it has disadvantage of sacrificing voice. Alternative procedure is Tracheoesophageal diversion but has higher complication rates. Definite - Irreversible Procedure It includes: Narrow field laryngectomy: it was considered as a gold standard prior to 1970s, when the irreversible procedures like laryngo tracheal separation were not done. Also Know Investigation of choice for diagnosing aspiration = Fibreoptic endoscopic evaluation of swallow (FESS) Videofluoroscopic modified Barium swallow (often called as ideofluoroscopy)
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ENT
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