Operative Otolaryngology: Laryngotracheal Separation

Introduction

1.
Airway protection is the most fundamental role of the mammalian larynx. (See Additional Sources for in-depth discussion.)
2.
For some patients, laryngeal function is compromised by disease processes to the extent that its airway protection role becomes inadequate in preventing aspiration.
3.
Chronic aspiration can be managed in most patients with alternative feeding, tracheostomy for pulmonary toilet, and oral care ( Box 21.1 ).
BOX 21.1

Treatment of Morbid Aspiration
Nonsurgical Strategies
- Nasoenteric tube feeding (or gastrostomy)
- Nothing by mouth
- Postural feeding technique
- Swallowing therapy
Adjunctive Surgical Procedures
- Cricopharyngeal myotomy
- Gastrostomy/feeding jejunostomy
- Tracheostomy
- Vocal cord injection or thyroplasty for vocal cord medialization
Definitive Surgical Procedures
- Glottic closure
- Laryngotracheal separation
  
  Laryngeal stenting
- Narrow-field laryngectomy
  
  Supraglottic closure
- Tracheal flap closure
- Tracheoesophageal diversion
4.
Occasionally patients cannot be managed satisfactorily by conservative measures. A variety of surgical strategies can be used (see Box 21.1 ).
5.
Among the surgical strategies, the most definitive, straightforward, and acceptable procedure is laryngotracheal separation (LTS) ( Fig. 21.1 ).

1.
Decision making regarding surgical intervention with LTS is more difficult than the procedure itself.
2.
The anatomy of the tracheoesophageal party wall facilitates the safe performance of LTS in that a layer of loose areolar tissue separates the membranous posterior wall of the trachea from the esophagus.
3.
The posterior wall of the trachea is a fibrous layer contiguous with the perichondrium of the tracheal rings and the inter-ring connective tissue that permits circumferential dissection of the trachea.
4.
Removing and weakening tracheal rings permits closure of the proximal stump of the trachea.

1.
General—degree of frailty, nutritional and cognitive status, communication skills, open wounds in head and neck region
2.
Laryngopharyngeal endoscopic examination

Vocal cord mobility—is there any motion?

Glottic closure—Can the glottis close to protect the airway? Is there an alternative strategy based on enhancing closure?

Pooling of secretions. Often extent of secretions precludes examination
3.
Oral cavity

Is the patient able to handle his or her secretions?

Tongue and palate mobility. Even if aspiration is controlled inability to move tongue or absence of the tongue may prevent swallowing.
4.
Neck

Prior tracheostomy?

Position of tracheostomy?

Is there adequate trachea available above stoma for closure?

Not required for this procedure

1.
Morbid aspiration with recurrent episodes of pneumonia not adequately managed by conservative measures
2.
No acceptable alternative
3.
Patient and family desire the procedure
Patient, family, and other stakeholders need to recognize that most patients lose their ability to speak, if able to speak preoperatively, and less than ½ of patients who undergo LTS are able to swallow postoperatively. Some, but not all, patients are able to be discharged after aspiration has been controlled.

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