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Chronic Aspiration


Key Points

  • Intractable aspiration results in chronic soilage of the lower respiratory tract and life-threatening pulmonary infections.

  • In adult patients, cerebrovascular accident with subsequent lower cranial nerve palsies is the most common cause of intractable aspiration; other causes include neuromuscular disorders, tumors (brainstem or laryngeal), postoperative aspiration, postradiation swallowing dysfunction, and traumatic or anoxic brain injury.

  • Common causes of intractable aspiration in pediatric patients include cerebral palsy, anoxic encephalopathy, sequelae of neurologic trauma or surgery, tracheoesophageal fistula, and other severe congenital or acquired neurologic disorders.

  • Initial conservative treatments of chronic aspiration include nothing-by-mouth status with an alternative route of alimentation, elevation of the head of the bed, and aggressive pulmonary toilet.

  • Patients with continued aspiration despite such conservative measures are deemed to have intractable aspiration; surgical management should be considered in these patients.

  • Phonation, swallowing, morbidity as a result of aspiration, and prognosis for neurologic recovery should all be considered in the choice of surgical approach for aspiration.

  • The Lindeman procedures, tracheoesophageal diversion and laryngotracheal separation, have gained popularity owing to their high rate of success in controlling aspiration and their technical simplicity.

The three major functions of the larynx—respiration, phonation, and airway protection—are intimately related. Impairment of laryngeal protective function can result in aspiration, the laryngeal penetration of secretions such as saliva, ingested liquids or solids, or refluxed gastric contents below the level of the true vocal cords.

A certain amount of aspiration is known to occur normally. Scintigraphic evaluation of healthy controls during sleep reveals aspiration in nearly 50%. A certain amount of aspiration may be tolerated without complications, provided that tracheobronchial clearance is normal and defense mechanisms are intact. Contamination of the respiratory tract associated with aspiration can result in a spectrum of bronchopulmonary complications. The severity of complications depends on the volume and the character (e.g., pH) of the aspirated material. Respiratory complications of aspiration include bronchospasm, airway obstruction, tracheitis, bronchitis, pneumonia, pulmonary abscess, sepsis, and death. Significant aspiration results in a high mortality rate.

Aspiration may be an isolated event related to temporary impairment of normal swallowing mechanisms and airway protection. Typically, isolated aspiration occurs secondary to neurologic dysfunction. This dysfunction may, in turn, be secondary to a depressed state of consciousness related to drugs, alcohol, or metabolic derangement. In addition, seizure, injury, or infection may cause isolated aspiration. Elderly patients are more likely to experience aspiration, presumably in relation to physiologic and neurologic changes associated with age. Patients with dentures experience impaired swallowing with decreased oral sensation and oral control, which may contribute to aspiration.

Chronic or intractable aspiration entails repeated episodes of aspiration. Patients with chronic aspiration require evaluation and effective management to prevent life-threatening complications. This chapter discusses the evaluation and management of patients with chronic aspiration and emphasizes surgical management.

Etiology

Chronic aspiration usually results from a severe loss of laryngeal protective function related to impaired motor activity or sensory loss. Despite healthy laryngeal function, chronic aspiration can occur if dysfunctional swallowing is significant.

Box 65.1 lists causes of chronic aspiration in adults. The most common inciting event is a cerebrovascular accident (CVA), particularly one that involves the brainstem with bilateral cranial nerve deficits. In addition, degenerative neurologic diseases are frequently associated with chronic aspiration. Neuromuscular diseases, muscular disorders, and peripheral nerve disorders, particularly those that involve the cranial nerves, can cause recurrent aspiration. Diffuse neurologic dysfunction from head injury, anoxic brain injury, infection, or drug toxicity can cause severe dysfunction and chronic aspiration. Chronic aspiration can also result from disorders of the pharynx and the esophagus, including neoplasms, postoperative and postirradiation dysfunction, Zenker diverticulum, stricture, and severe gastroesophageal reflux.

Box 65.1
Causes of Chronic Aspiration

  • Cerebrovascular accidents

  • Atherosclerotic thrombosis

  • Embolism

  • Intracranial hemorrhage

Degenerative Neurologic Diseases

  • Parkinson disease

  • Amyotrophic lateral sclerosis

  • Progressive supranuclear palsy

  • Multiple sclerosis

Neuromuscular and Muscular Disorders

  • Poliomyelitis

  • Myasthenia gravis

  • Muscular dystrophy

  • Myopathies

Peripheral Nerve Disorders

  • Cranial nerves

  • Guillain–Barré syndrome

  • Intracranial neoplasms

  • Primary dysfunction related to neoplasm

  • Postsurgical dysfunction

  • Trauma

  • Closed head injury

  • Hematoma

  • Anoxic brain injury

  • Intracranial infection

Pharyngeal Disorders

  • Neoplasms

  • Postsurgical dysfunction

  • Postirradiation dysfunction

  • Zenker diverticulum

  • Cricopharyngeal dysfunction

  • Stricture

Esophageal Disorders

  • Reflux

  • Achalasia

  • Caustic injury

Miscellaneous

  • Severe illness

  • Multisystem disease

  • Drug intoxication

In pediatric patients, chronic aspiration is most commonly related to severe neurologic dysfunction resulting from cerebral palsy, anoxic encephalopathy, sequelae of neurologic trauma or surgery, tracheoesophageal fistula, or other severe congenital or acquired neurologic disorders.

Symptoms

Patients may be aware of recurrent aspiration and may describe episodes of coughing or choking during swallowing. Some patients, however, may experience silent aspiration, whereby cough does not occur after laryngeal penetration. Fever and respiratory symptoms, such as productive cough with purulent sputum, may occur and indicate an infectious complication. Patients may have weight loss, dysphonia, pain, dysphagia, odynophagia, or other symptoms, depending on the cause of the underlying disorder. Frequently, patients are severely ill from comorbid conditions and secondary infectious complications.

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