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Abstract Background Owing to recurrent aspiration pneumonia and airway stenosis secondary to thoracic deformities, tracheostomy or laryngotracheal separation are often necessary in children with severe motor and intellectual disabilities. However, these procedures are associated with the risks of tracheal stenosis due to tracheal granulation and tracheoinnominate artery fistula formation. We report a case of a child with severe motor and intellectual disabilities treated with an anterior mediastinal tracheostomy. Case presentation The patient was a 15-year-old boy with severe motor and intellectual disabilities due to intractable epilepsy. Due to thoracic deformity and tracheomalacia, the patient had a flattened and narrowed trachea. Accordingly, laryngotracheal separation was performed 4 months before admission to avoid aspiration pneumonia. Due to a common cold, the patient required frequent sputum suctioning, which exacerbated the tracheal stenosis. Bronchoscopy revealed tracheal stenosis 4–5 cm caudal to the tracheostomy site, tracheal mucosal ulcers, and pulsation of the innominate artery on the anterior wall of the trachea. We performed an anterior mediastinum tracheostomy to release the tracheal stenosis and prevent tracheoinnominate artery fistula formation. Conclusions Anterior mediastinal tracheostomy has several advantages. Including sufficient release of bony compression, release of tracheal hyperextension, and relief of tracheal and innominate artery contact ensures a cannula-free tracheostomy, and there is no need to dissect the brachiocephalic artery. It is the procedure of choice in cases of head and neck malignancies requiring extensive tracheal resection and could be a good surgical option for severe tracheal stenosis and tracheoinnominate artery fistula in children with severe motor and intellectual disabilities.

A 15-year-old girl presented with a 3-year-history of continuous outflow of saliva from a pharyngocutaneous fistula, located at 5 mm superior to her tracheal stoma. She was diagnosed with Miller-Dieker syndrome at birth. At 2 years of age, pediatric surgeons at our institution carried out laryngotracheal separation to prevent aspiration pneumonia. At the age of 12 years, she developed continuous saliva discharge from the fistula. We performed central-part laryngectomy and resection of the pharyngocutaneous fistula, which relieved her from the continuous saliva discharge. Central-part laryngectomy is less invasive and easier to perform than total laryngectomy. We hereby present a case and retrospective analysis of 12 patients, who underwent central-part laryngectomy. [ABSTRACT FROM AUTHOR]

Background: Owing to recurrent aspiration pneumonia and airway stenosis secondary to thoracic deformities, tracheostomy or laryngotracheal separation are often necessary in children with severe motor and intellectual disabilities. However, these procedures are associated with the risks of tracheal stenosis due to tracheal granulation and tracheoinnominate artery fistula formation. We report a case of a child with severe motor and intellectual disabilities treated with an anterior mediastinal tracheostomy. Case presentation: The patient was a 15-year-old boy with severe motor and intellectual disabilities due to intractable epilepsy. Due to thoracic deformity and tracheomalacia, the patient had a flattened and narrowed trachea. Accordingly, laryngotracheal separation was performed 4 months before admission to avoid aspiration pneumonia. Due to a common cold, the patient required frequent sputum suctioning, which exacerbated the tracheal stenosis. Bronchoscopy revealed tracheal stenosis 4–5 cm caudal to the tracheostomy site, tracheal mucosal ulcers, and pulsation of the innominate artery on the anterior wall of the trachea. We performed an anterior mediastinum tracheostomy to release the tracheal stenosis and prevent tracheoinnominate artery fistula formation. Conclusions: Anterior mediastinal tracheostomy has several advantages. Including sufficient release of bony compression, release of tracheal hyperextension, and relief of tracheal and innominate artery contact ensures a cannula-free tracheostomy, and there is no need to dissect the brachiocephalic artery. It is the procedure of choice in cases of head and neck malignancies requiring extensive tracheal resection and could be a good surgical option for severe tracheal stenosis and tracheoinnominate artery fistula in children with severe motor and intellectual disabilities. [ABSTRACT FROM AUTHOR]

Background: Stenosis of the permanent tracheostoma causes the patient reduced quality of life. We herein report a treatment of permanent tracheostomal stenosis with local steroid injection after laryngotracheal separation in a patient with severe motor and intellectual disabilities. Case presentation: The patient was a 22-year-old woman with congenital myopathy who underwent laryngotracheal separation at the age of 21 years. Tracheostomal enlargement was performed at the age of 22 years. Two months after the operation, permanent tracheostomal stenosis developed owing to a hard cicatricial constriction. Although the size of the tracheostoma decreased, yet the patient did not have any respiratory distress. Therefore, we started local steroid injection therapy using triamcinolone acetonide instead of revision surgery. After those 3 injections, the tracheostomal stenosis was apparently dilated. The patient received this treatment 19 times in 3 years and 4months. She has not needed this treatment in the past 1 year and 8 months. No adverse effect of the corticosteroid was seen during the 5-year period. Conclusions: On the basis of our experience, if patients have no symptoms related to stenotic airway obstruction, triamcinolone acetonide injection therapy, instead of revision surgery, is a simple, safe, and highly effective procedure for permanent tracheostomal stenosis.

Abstract Background Surgery to prevent aspiration has complications related to tracheostomy tube, such as the trachea-brachiocephalic artery fistula. Glottic closure procedure makes tracheostoma at a position higher than the first ring of the trachea and theoretically has a potential to prevent such complications owing to a longer distance between the tip of tracheostomy tube and the tracheal membrane adjacent to the brachiocephalic artery. Our aim is to evaluate the safety of glottic closure in neurologically impaired patients by comparing outcomes with laryngotracheal separation. Methods This study is a single-center retrospective study from 2004 to 2019, using data of 15 and 12 patients who underwent glottic closure (GC) and laryngotracheal separation (LTS). The primary outcome was the incidence of postoperative complications induced by tracheostomy tube placement and adjustment of the tracheostomy tube position to prevent these complications, such as by converting to a length-adjustable tube and/or placing gauze between the skin and tube flange. Additionally, we analyzed the anatomical relationship between the tracheostomy tube tip and brachiocephalic artery and measured the distance between them using postoperative CT images. Results No patients in either group had trachea-brachiocephalic artery fistula. Erosion or granuloma formation occurred in 1 patient (7%) and 4 patients (33%) in the GC and LTS groups, respectively. Adjustment of the tracheostomy tube was needed in 2 patients (13%) and 6 patients (50%) in the GC and LTS groups. CT revealed a higher proportion of patients with the tracheostomy tube tip superior to the brachiocephalic artery in GC than LTS group. The mean tracheostoma-brachiocephalic artery distance was 40.8 and 32.4 mm in the GC and LTS groups. Conclusions Glottic closure reduces the risk of postoperative complications related to a tracheostomy tube. This may be due to the higher position of the tracheostoma at the level of the cricoid cartilage, increasing the distance between the tracheostoma and brachiocephalic artery.

Abstract A severe Angelman syndrome (AS) patient with a very large deletion (19.3 Mb) at 15q11.2‐q14 required laryngotracheal separation, which is not a common surgery in AS. Comparative genomic hybridization‐based microarrays can be useful to confirm deletion size and clinical severity.

Methyl-CpG binding protein 2 gene (MECP2) is located on the X chromosome (Xq28) and is important for nervous and immune system functioning. Patients with MECP2 duplication syndrome (MDS) have recurrent respiratory infections (RRIs). Although RRIs often occur with MDS because some patients with MDS also have hypoimmunoglobulinemia and duplication of the interleukin-1-receptor-associated kinase-1 gene (IRAK1), which is also located on Xq28, the phenotype of IRAK1 duplication in patients with MDS remains unclear. The clinical course of three patients with MDS who underwent laryngotracheal separation (LTS) at two institutions was summarized. Three patients with MDS were identified to have recurrent pneumonia characteristic of aspiration pneumonia, sometimes requiring artificial ventilation therapy; they had no other bacterial infections. After LTS, they rarely had pneumonia. In MDS, MECP2 expression increased two-fold naturally, while IRAK-1 expression showed no difference compared with a healthy subject. Since RRIs in MDS are thought to be caused by aspiration and not susceptibility to infection previously estimated to be major complication, the evaluation of aspiration is recommended for RRIs for better management of MDS. [ABSTRACT FROM AUTHOR]

Fungal laryngotracheitis (FLT) is rare, and the diagnosis can be challenging, as its presentation lacks specificity and may resemble other conditions such as granulomatous disease, gastroesophageal reflux, or malignancy. FLT can be very invasive, causing complete laryngotracheal separation, leading to a non-functioning larynx. We report a 39-year-old Indian woman with diabetes who presented to the emergency department with a sore throat, hoarseness, dysphagia, and stridor for two days. Initially treated for diabetic ketoacidosis due to acute tonsillopharyngitis, she required intubation for airway obstruction and severe metabolic acidosis. Fourteen days post-intubation, an airway assessment revealed bilateral vocal fold edema and pus in the subglottic and cervical trachea. CT imaging showed circumferential fluid around the trachea and a distorted larynx. Examination under anesthesia and neck exploration revealed pus around the thyroid gland and trachea, leading to a tracheostomy and sample collection. Histopathology indicated a fungal infection, confirmed as Candida guillermondii with Escherichia coli . The patient was treated with oral fluconazole and intravenous cefuroxime for four weeks. Despite treatment, a repeat CT indicated a non-functioning larynx, prompting a proposal for a total laryngectomy. After a multidisciplinary discussion, it was decided to continue antifungal therapy due to the patient's clinical improvement. At follow-up a month later, she was stable, tolerating oral intake with a double-lumen tracheostomy tube. This case underscores the importance of a high index of suspicion for FLT and the need for patient-specific decisions regarding total laryngectomy in a non-functioning larynx., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Baharudin et al.)

Background: Surgery to prevent aspiration has complications related to tracheostomy tube, such as the trachea-brachiocephalic artery fistula. Glottic closure procedure makes tracheostoma at a position higher than the first ring of the trachea and theoretically has a potential to prevent such complications owing to a longer distance between the tip of tracheostomy tube and the tracheal membrane adjacent to the brachiocephalic artery. Our aim is to evaluate the safety of glottic closure in neurologically impaired patients by comparing outcomes with laryngotracheal separation.Methods: This study is a single-center retrospective study from 2004 to 2019, using data of 15 and 12 patients who underwent glottic closure (GC) and laryngotracheal separation (LTS). The primary outcome was the incidence of postoperative complications induced by tracheostomy tube placement and adjustment of the tracheostomy tube position to prevent these complications, such as by converting to a length-adjustable tube and/or placing gauze between the skin and tube flange. Additionally, we analyzed the anatomical relationship between the tracheostomy tube tip and brachiocephalic artery and measured the distance between them using postoperative CT images.Results: No patients in either group had trachea-brachiocephalic artery fistula. Erosion or granuloma formation occurred in 1 patient (7%) and 4 patients (33%) in the GC and LTS groups, respectively. Adjustment of the tracheostomy tube was needed in 2 patients (13%) and 6 patients (50%) in the GC and LTS groups. CT revealed a higher proportion of patients with the tracheostomy tube tip superior to the brachiocephalic artery in GC than LTS group. The mean tracheostoma-brachiocephalic artery distance was 40.8 and 32.4 mm in the GC and LTS groups.Conclusions: Glottic closure reduces the risk of postoperative complications related to a tracheostomy tube. This may be due to the higher position of the tracheostoma at the level of the cricoid cartilage, increasing the distance between the tracheostoma and brachiocephalic artery. [ABSTRACT FROM AUTHOR]

• Laryngotracheal separation is the definitive solution to intractable aspiration pneumonia in neurologically impaired children. • Tracheo-innominate artery fistula is a potentially fatal complication. • Surgical options depend on whether patients have the pre-existing tracheostomy or can transect the trachea above the tracheostomy site. • Appropriate angle and length of the cannula should be selected. Laryngotracheal separation (LTS) is known to be the definitive solution for intractable aspiration pneumonia in neurologically impaired children. Postoperatively, a tracheostomy cannula is usually required. However, there are fatal cannula related complications such as a tracheo-innominate artery fistula (TIAF). We present our methods of preventing TIAF. A retrospective review in a single center from 2011 to 2019 identified 57 cases treated with LTS. We divided them into three groups: no pre-existing tracheostomy (n = 26), pre-existing tracheostomy with preservation of the pre-existing fistula (n = 20), and pre-existing tracheostomy without preservation of the pre-existing fistula (n = 11). The first group underwent traditional modified Lindeman's procedure. The second received transection of the trachea above the tracheostomy site, while the third had transection of the trachea at the tracheostomy site and creation of a distal end tracheostomy. Proper length and the angle of the cannula were selected to prevent damaging the innominate artery by the tip of the cannula. If the innominate artery compressed the trachea anteriorly, prophylactic arterial transection was considered. Three patients (5.3%) died from causes unrelated to the surgical treatment. Only one patient had a postoperative TIAF followed by LTS (1.8%). Other postoperative complications were: wound infection (8.8%), intratracheal granuloma (12.3%), intratracheal minor bleeding (10.5%), wound granuloma (43.9%), leakage (1.8%). No one required revision of LTS. Success rates of LTS were high without major complications in all three groups and implies a safe operation and a definitive solution to intractable aspiration. [ABSTRACT FROM AUTHOR]

A severe Angelman syndrome (AS) patient with a very large deletion (19.3 Mb) at 15q11.2‐q14 required laryngotracheal separation, which is not a common surgery in AS. Comparative genomic hybridization‐based microarrays can be useful to confirm deletion size and clinical severity. [ABSTRACT FROM AUTHOR]

It is impossible to secure the airway of a patient with "neck-only" breathing transorally or transnasally. Surgical removal of the larynx (laryngectomy) or tracheal rerouting (tracheoesophageal diversion or laryngotracheal separation) creates anatomic discontinuity. Misguided attempts at oral intubation of neck breathers may cause hypoxic brain injury or death. We present national data from the American Academy of Otolaryngology-Head and Neck Surgery, the American Head and Neck Society, and the United Kingdom's National Reporting and Learning Service. Over half of US otolaryngologist respondents reported instances of attempted oral intubations among patients with laryngectomy, with a mortality rate of 26%. UK audits similarly revealed numerous resuscitation efforts where misunderstanding of neck breather status led to harm or death. Such data underscore the critical importance of staff education, patient engagement, effective signage, and systems-based best practices to reliably clarify neck breather status and provide necessary resources for safe patient airway management. [ABSTRACT FROM AUTHOR]

Competing Interests: None

Purpose: Tracheoesophageal diversion (TED) is an effective therapeutic procedure for intractable aspiration. In this study, we performed TED in cases of intractable aspiration and/or repetitive pneumonia, investigated the main route of nutritional uptake after the procedure, and evaluated the swallowing method using videofluoroscopy. We also evaluated the validity of TED for treating intractable aspiration. Methods: We retrospectively reviewed 44 patients (30 male and 14 female patients; median age, 55 years; range 15–85 years) who underwent TED for the treatment of intractable aspiration between January 2008 and December 2017. We examined the route of nutritional uptake before and after the operation and performed videofluoroscopy to detect the swallowing method after the operation. Results: The percentage of patients with oral intake increased from 21% (9/44) before TED to 56% (25/44) within 1 month after TED (p < 0.01); this percentage included patients with poor preoperative swallowing function. Overall, 60% patients who were able to communicate and mobilize using a wheelchair as well as 92% patients who were able to communicate and mobilize in the supine position were able to consume food orally. We subsequently performed videofluoroscopy in 24 of the 25 patients with oral intake and assessed the passage route of the contrast agent, which was found to move through the laryngeal route in 54% of these patients. Conclusion: TED may be suitable for the treatment of intractable aspiration and can improve oral intake, particularly in patients with good mobility and communication ability. [ABSTRACT FROM AUTHOR]

Laryngotracheal separation (LTS) is the most immediately life-threatening airway injury. LTS is so rare that very few otolaryngologists have experience with it. LTS is one of the diagnostic and therapeutic challenges in airway diseases and its management remains to be established. We experienced a patient with complete LTS after attempted hanging. A high index of suspicion, adequate imaging, prompt airway establishment and early surgical repair are the most vital factors in managing a patient with LTS.

Stenosis of the permanent tracheostoma causes the patient reduced quality of life. We herein report a treatment of permanent tracheostomal stenosis with local steroid injection after laryngotracheal separation in a patient with severe motor and intellectual disabilities. The patient was a 22-year-old woman with congenital myopathy who underwent laryngotracheal separation at the age of 21 years. Tracheostomal enlargement was performed at the age of 22 years. Two months after the operation, permanent tracheostomal stenosis developed owing to a hard cicatricial constriction. Although the size of the tracheostoma decreased, yet the patient did not have any respiratory distress. Therefore, we started local steroid injection therapy using triamcinolone acetonide instead of revision surgery. After those 3 injections, the tracheostomal stenosis was apparently dilated. The patient received this treatment 19 times in 3 years and 4months. She has not needed this treatment in the past 1 year and 8 months. No adverse effect of the corticosteroid was seen during the 5-year period. On the basis of our experience, if patients have no symptoms related to stenotic airway obstruction, triamcinolone acetonide injection therapy, instead of revision surgery, is a simple, safe, and highly effective procedure for permanent tracheostomal stenosis. • Permanent tracheostomal stenosis (PTS) can cause the patient reduced quality of life. • We show a conservative treatment with local steroid injection therapy using triamcinolone acetonide (TAC). • If patients have no symptoms related to stenotic airway obstruction, TAC injection therapy, instead of revision surgery, is a simple, safe, and highly effective procedure for PTS to maintain their QOL. [ABSTRACT FROM AUTHOR]

Less than one percent of trauma admission cases are categorized as pediatric neck trauma [13] . Nevertheless, due to an increasingly mobile society, there has been an increasing frequency of pediatric neck trauma with motor vehicle accidents being the most common mechanism of injury [8] . We present a case of laryngotracheal separation from a blunt, clothesline injury to the neck in a pediatric patient. We also review the literature and discuss the benefit of balloon airway dilation and its assistance in the management of laryngeal trauma and its resultant effects. [ABSTRACT FROM AUTHOR]

Pediatric laryngotracheal injuries from blunt neck trauma are extremely rare, but can be potentially catastrophic. Early diagnosis and skillful airway management is critical in avoiding significant morbidity and mortality associated with these cases. We present a case of a patient who suffered a complete tracheal transection and cervical spine fracture following a clothesline injury to the anterior neck. A review of the mechanisms of injury, clinical presentation, initial airway management, and anesthetic considerations in laryngotracheal injuries from blunt neck trauma in children are presented. [ABSTRACT FROM AUTHOR]

Conclusions: Tracheoesophageal diversion (TED) and laryngotracheal separation (LTS) can prevent aspiration pneumonia and improve the morbidity of patients with severe motor and intellectual disability (SMID). By improving hospitalization rates and care needs, the quality-of-life can be improved for the patients and their parents. Objectives: This study evaluated the clinical outcomes of TED and LTS in patients with intractable aspiration and SMID. Methods: This study retrospectively reviewed patients with SMID and intractable aspiration pneumonia who underwent TED or LTS at the institution between January 2008 and January 2015. It assessed the frequency of sputum suctioning, the number of pre-operative and post-operative hospitalizations, the operative time, and complications. Results: Forty patients were identified during the study period. After surgery, there were significant reductions in the frequency of secretion suctioning (from 165.0 times/day to 33.0 times/day) and the number of hospitalizations because of aspiration pneumonia (from 5.4 times/year to 0.2 times/year). A tracheocutaneous fistula occurred in one (2.5%) patient, and two (5.4%) patients developed tracheoinnominate artery fistulas. In the latter group, the innominate arteries were successfully ligated and endovascular embolization was performed. [ABSTRACT FROM AUTHOR]

Intractable aspiration is a serious, often life-threatening condition due to its potential impact on pulmonary function. Aspiration requires therapeutic measures, starting with conservative management but often necessitating surgical treatment. The basic surgical principle is to separate the alimentary and respiratory tracts through a variety of procedures which, unfortunately, nearly all result in the loss of phonation, with the exception of total laryngectomy (TL) which includes the placement of an indwelling voice prosthesis. In this study, we present a modified laryngotracheal separation (LTS) technique that, we believe, offers multiple advantages compared to standard TL. After reviewing the medical records of 35 patients with intractable aspiration who have undergone LTS, we describe the surgical technique and present the postoperative result. In a second surgical procedure about two months following LTS, we aimed to achieve voice restoration by placement of an indwelling voice prosthesis. Intractable aspiration was successfully treated in all patients. Placement of an indwelling voice prosthesis during a second operation was successful in 15 patients, representing the largest reported cohort thus far. LTS is a reliable surgical technique to treat intractable aspiration, with restoration of oral intake, thereby improving the general condition and quality of life of these unfortunate patients. Furthermore, voice restoration can be achieved in selected patients, by placement of a voice prosthesis. [ABSTRACT FROM AUTHOR]

There is a risk of developing a fatal trachea-innominate artery fistula following laryngotracheal separation for the prevention of intractable aspiration pneumonia. We developed a novel technique of surgical closure of the larynx to avoid this complication and provide long-term cannula-free care. [ABSTRACT FROM AUTHOR]

Aim of the study Sialorrhoea and chronic salivary aspiration are a major problem in many neurologically impaired children causing embarrassment, skin issues and recurrent lower respiratory tract infections (LRTI). The aim of this study was to assess the efficacy of salivary gland surgery in the treatment of chronic salivary aspiration in such children. Objectives To compare admission rates for LRTI per annum before and after surgical intervention. Methods Retrospective review of all patients who underwent salivary management surgery for chronic aspiration under Princess Margaret Hospital's (PMH) Otolaryngology department from 2006 until 2013. Results Twelve patients were included in this review. Their ages ranged from 3 to 21 years (mean = 11.4). Their genders were equally distributed. Two patients had underlying congenital disorders; one had an acquired brain injury, while the majority ( n = 9, 75%) had cerebral palsy secondary to a sustained perinatal injury. Most patients ( n = 11, 91.7%) had bilateral submandibular gland excision and parotid duct ligation as a primary procedure. One patient had a laryngotracheal separation. Two patients went on to have a second procedure. The mean follow up time was five years. Using Wilcoxon Signed-Rank test we showed that the median rate of admission per annum for LRTI pre-operatively was 1.0. This was reduced to 0.5 post-operatively, which was statistically significant ( p ≤ 0.05). Conclusions We hypothesize that the combination of bilateral submandibular gland excision and bilateral parotid duct ligation is effective in reducing admissions with aspiration pneumonia in neurologically impaired children, and therefore improves the quality of life in these patients. [ABSTRACT FROM AUTHOR]

Abstract: Laryngotracheoesophageal cleft (LTEC) is an extremely rare congenital malformation that is difficult to treat. We present a female patient with type 4 LTEC associated with multiple significant malformations. She suffered from a severe asthma attack due to aspiration of saliva, and it was determined that she should undergo surgery for associated congenital heart disease as early as possible to ensure long-term survival. Therefore, we performed laryngotracheal separation with an end-tracheostomy to completely and immediately prevent aspiration. She was then able to undergo radical surgery for her congenital heart disease. She recovered well postoperatively, and long-term survival is expected. [Copyright &y& Elsevier]

Abstract: Objective: Outcomes of tracheoesophageal diversion and laryngotracheal separation were evaluated in 15 neurologically impaired children treated for intractable aspiration. Methods: A retrospective analysis of the hospital records was carried out in 15 consecutive pediatric patients who underwent either tracheoesophageal diversion or laryngotracheal separation with trumpet-shaped tracheotomy from 1999 to 2006 in Kagawa Children''s Hospital. Results: The number of hospital admissions for aspiration pneumonia after surgery was significantly decreased in 6 patients who were cared for at home. The parent-reported number of secretion suctioning was decreased after surgery especially in patients with pre-operative tracheotomy or intubation. Four patients fed through naso-gastric tube progressed with oral diet post-operatively, whereas 3 patients who had pre-operative tracheotomy developed temporary post-operative tracheocutaneous fistula that was managed by local wound care. Conclusion: It is suggested that tracheoesophageal diversion and laryngotracheal separation decrease the morbidity of pediatric patients and improve their quality of life and that of their parents. It is suggested that the risk of developing post-operative fistula is higher in pediatric patients with than without pre-operative tracheotomy. [Copyright &y& Elsevier]

Objectives: Laryngotracheal separation (LTS) is an ideal surgical method for intractable aspiration; however, the oral side of the trachéal stump can easily disintegrate. Therefore, we developed a modified LTS method. We performed sub- glottic laryngeal closure (SGLC) as a new surgical method and evaluated the outcomes. Methods: We retrospectively analyzed the medical records of 36 patients (28 male and 8 female; 15 to 91 years of age) who underwent SGLC between 2007 and 2011 at Tottori University Hospital, Japan. Operative data (operative time, intraoperative bleeding, and time to drain removal), outcomes (aspiration and changes in nutritional status), and complications with regard to the surgical method were examined. The occurrence of a subcutaneous proximal laryngeal stump fistula was evaluated by videofluoroscopy. Results: The SGLC was performed safely in all patients. Fistulization was observed in only 1 of the patients (2.8%), and major bleeding after surgery was observed in 1 patient (2.8%). The procedure relieved aspiration pneumonia in all patients. Conclusions: We conclude that SGLC is effective for treating and preventing pulmonary aspiration. The incidence of postoperative complications, particularly that of subcutaneous fistulas, was very low. Therefore, this method may be useful for patients in poor condition. [ABSTRACT FROM AUTHOR]

Animal-induced trauma can lead to severe injury and death, especially in medically isolated settings. Few reports of hyena attacks on humans have been reported in the literature. The goal of this report is to describe such an attack and the heroic efforts required to preserve life and function in a resource-limited environment. A 55-year-old female was attacked by a hyena in a rural region of Ethiopia. Despite delays in medical care, she was able to survive this attack and was successfully discharged after prolonged treatment efforts. Animal-induced trauma is a potential source of substantial and disfiguring injury, especially in resource-limited environments. Early transfer to tertiary care centers and creative solutions are needed to optimize outcomes in such environments., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Macielak et al.)

Objectives/Hypothesis: Recurrent pneumonia due to intractable aspiration is a life-threatening disease. A tracheal flap method for children without previous tracheostomy has been previously reported. This study reports that improvements of this method and its three subtypes are widely applicable to patients with various conditions. Study Design: Surgical technique study. Methods: The tracheal flap method does not involve transection of the trachea but achieves laryngotracheal separation using the tracheal, mucoperichondrial, and sternohyoid muscle, along with anterior cervical skin flaps. This method can be divided into three subtypes as follows: A-type, utilizing the tracheal flap (for patients without previous tracheostomy); B-type, utilizing the mucoperichondrial and sternohyoid muscle flaps (for patients lacking an anterior tracheal wall); and C-type, utilizing the esophageal flap (for patients with severe hypersalivation). In all three subtypes, the anterior cervical skin flap is employed. Results: The tracheal flap method was performed in 30 patients (24 children and six adults) at risk of developing intractable aspiration pneumonia. In all 30 cases, aspiration pneumonia was prevented without severe complications. No fistula formation was observed. Conclusions: All three subtypes (A-, B-, and C-type) of the tracheal flap method are effective in preventing the recurrence of aspiration pneumonia. This method is applicable to diverse patient backgrounds regardless of age or previous tracheostomy. It is less invasive than Lindeman procedure. Furthermore, this method is acceptable to patients' families and improves the QOL of both patients and caregivers. Laryngoscope, 2012 [ABSTRACT FROM AUTHOR]

Objectives: Laryngotracheal separation (LTS) is an uncommonly performed but highly effective procedure for intractable aspiration in patients with amyotrophic lateral sclerosis and other neurodegenerative conditions. Previously published series have noted rates of postoperative tracheocutaneous fistula formation as high as 1 in 3 patients. This report details tin-use of a muscle flap-reinforced imbrication technique to reduce the incidence of fistula formation after LTS surgery. Methods: All patients who underwent LTS surgery at the reporting institutions between 2004 and 2010 were identified. The principal diagnosis, patient characteristics, the presence of a preexisting tracheotomy, and postoperative complications were recorded. We describe the technique for imbrication closure of the proximal stump with strap muscle reinforcement. Results: Thirteen patients (10 male, 3 female; median age, 53 years; interquartile range, 45 to 66 years) underwent the LTS procedure; amyotrophic lateral sclerosis was the principal diagnosis in 8 of the 13 patients. Six patients had a preexisting tracheotomy. None developed tracheocutaneous fistula, hematoma, or wound infection. Two patients required stomaplasty at a later date. Conclusions: Strap muscle flap-reinforced imbrication closure of the proximal tracheal stump after LTS surgery allows for a low incidence of postoperative fistula formation. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Tracheoinnominate artery fistula (TIF) is an often fatal complication of laryngotracheal separation (LTS) for which there has been no systematic therapeutic strategy for prevention or management of TIF. The aim of this study was to establish such a strategy based on our clinical experience. Materials and Methods: From 2000 to 2010, 14 patients received LTS. We reviewed these patients to develop a therapeutic approach to prevent or manage TIF. Results: Three patients had major bleeding, and another 3 received preventive treatment before major bleeding. In the major bleeding group, 1 patient died of choking from uncontrollable hemorrhage, but the others were rescued by brachiocephalic trunk separation and/or endovascular embolization. At operation, median sternotomy with its high risk of mediastinitis was avoided. In the preventive treatment group, prophylactic brachiocephalic trunk separation was performed for 2 patients because their severe scoliosis narrowed the mediastinum, compressing the innominate artery on computed tomography. Another avoided major bleeding by converting the tracheostomy tube to a length-adjustable type. Conclusion: Tracheoinnominate artery fistula is a dramatic, often lethal complication. The strategic approach should be designed to prevent it and includes evaluation of the spinal deformity on computed tomography, brachiocephalic trunk separation at the same time as LTS, and recognizing the importance of “herald” or warning minor bleeds. [Copyright &y& Elsevier]

Objectives: Laryngotracheal separation is a surgical procedure used in the treatment of intractable aspiration. As with total laryngectomy and laryngotracheal diversion, this procedure requires postoperative pressure above the suture location to prevent leakage at the anastomosis. To date, there have been no reports regarding laryngeal separation without postoperative treatment. The purpose of this study was to evaluate a new surgical procedure for laryngotracheal separation that is performed without a cannula and requires no postoperative treatment. Methods: We performed the new surgical procedure in 7 patients. The mucosa of the cricoid cartilage was sutured to achieve tracheal closure. The closure was covered with a musculocutaneous flap of strap muscle; gauze was then tied over the skin and a 2-0 nylon suture was used to pierce the posterior part of the cricoid cartilage. In addition, a permanent tracheostoma was constructed without a tracheal cannula. Results: No patients required a tracheal cannula or treatment after the operation. Additionally, aspiration pneumonia was prevented without complications in all patients. Conclusions: This new surgical procedure eliminates the need for a cannula and postoperative treatment. The effects of this method in terms of aspiration prevention are comparable to those of other surgical techniques. [ABSTRACT FROM AUTHOR]

Summary: Objectives: Laryngeal fracture patients can present with a spectrum of clinical findings ranging from normal to airway collapse and death. We will therefore examine and emphasize clinical presentation, an algorithm for appropriate diagnosis and acute airway management, and radiological or physical examination findings and demonstrate the appropriate surgical approach for optimum clinical outcome in cases of blunt and penetrating laryngeal injury. Herein, we present one of the largest series of management of laryngeal and tracheal fractures from a tertiary care level I trauma center. Study Design: A retrospective chart review from 1998 to 2008. Methods: A retrospective chart analysis on patients presenting to the head and neck trauma service. Institutional review board approval was obtained before the start of the research. Results: Our series consisted of 11 men and one woman with a mean age of 41.8 years presenting with laryngeal fractures caused by blunt (n=10) or penetrating (n=2) trauma. One patient presented with complete laryngotracheal separation, which was successfully managed by immediate tracheotomy and early surgical intervention. The other 11 patients had a combination of conservative (n=6) and surgical (n=5) management. All patients who required a tracheotomy (n=7) were decannulated. Conclusions: Early suspicion and diagnosis of acute laryngeal and tracheal injuries are crucial. The airway must be secured via tracheotomy when possible. Computed tomography scans play a central role in diagnosis. Proper restoration of the laryngeal framework with appropriately timed open reduction and internal fixation is critical for optimal recovery of the airway, voice, and swallowing. [Copyright &y& Elsevier]

The aim of this study was to evaluate the long-term outcomes of the reversal of laryngotracheal separation (LTS) in patients who underwent extensive resection of tumors located in the upper aerodigestive tract. We performed a retrospective analysis of the medical records of eight patients who had LTS reversal. The operation was successful in six patients who were followed up for a period of 17-99 months (mean = 46.3 ± 26.2). The mean interval between LTS and surgical reversal was 16.6 ± 9.1 months. Four patients had postoperative complications: mild to moderate transient aspiration in two, tracheal stenosis in one, and severe aspiration followed by tracheal stenosis in one. In the last two cases, surgical reversal was not successful. The patients whose surgery was effective maintained oral feeding and comprehensible speech until the end of the follow-up period. We conclude that reversal of LTS is technically simple and, when successful, permits the return to oral feeding and comprehensible speech for an indefinite period of time. However, the frequency of complications and inefficacy of LTS reversal should not be overlooked. [ABSTRACT FROM AUTHOR]

Laryngotracheal separation is often performed to prevent intractable aspiration for children with severe mental and physical disabilities. However, tracheo-innominate artery fistula after surgery can occur as a severe complication and cause fatal hemorrhage. We have therefore developed a novel procedure to prevent tracheo-innominate artery fistula. Surgery was performed by making an H-shaped incision and creating skin flaps. The trachea was not raised anteriorly and the skin flaps were sutured to the trachea. We performed this procedure on nine patients, and no major complications occurred in any case. This procedure can be expected to reduce the occurrence of tracheo-innominate artery fistula. [ABSTRACT FROM AUTHOR]

We report preventive innominate artery division or ligation through a suprasternal approach for impending tracheo-innominate artery fistula (TIF) with recurrent airway oozing in patients with severe neuromuscular disease. Our approach is less invasive and a favorable procedure as preventive surgery for impending TIF. [ABSTRACT FROM AUTHOR]

Summary: Introduction: Neonatal brainstem dysfunction (NBD) associates four symptoms of variable presence and intensity: suction-swallowing dysfunction, abnormal laryngeal sensitivity and motility, gastroesophageal reflux, and cardiac vagal overactivity. Materials and methods: We report three cases of severe NBD with chronic aspiration which required surgical management. Successive failures and clinical deterioration led us to perform laryngotracheal separation. The surgical procedure consisted in suturing the distal segment of the trachea to the cervical skin after complete closure of the larynx. Results: After surgery, these children did not present any pulmonary infection and were allowed oral nutrition. However, oral communication was no longer possible. Although it is a theoretically reversible procedure, the decision is ethically difficult in children free of mental deficiency, because of the vocal loss and the unpredictable NBD outcome. Conclusion: Laryngotracheal separation may be recommended after multidisciplinary decision for severe chronic aspiration in the particular case of children presenting with NBD. [ABSTRACT FROM AUTHOR]

Laryngotracheal separation is a simple and reliable operation for the treatment of patients with repetitive and intractable aspiration; however, it is apprehended that pooling in the tracheal blind pouch may cause postoperative complications. In the present study, we examined drainage of the blind pouch created by laryngotracheal separation. Fourteen patients aged 3–63 years with repetitive aspiration pneumonia underwent laryngotracheal separation by the modified Lindeman procedure. A barium swallow was performed 10–30 days after surgery. X-rays of the lateral view of the neck were taken at 6 and 24 h after the swallow, and then every 24 h until the contrast medium cleared. The contrast medium in the blind pouch cleared within 24 h in nine patients. In the remaining five, the clearance time was ≤48 and ≤72 h in two patients each, and 96 h in one patient. The clearance time in patients aged under 20 years was ≤24 h, while middle-aged to elderly patients showed prolonged clearance time. No late complications of the blind pouch, such as infections, were observed. The potential risk of complications caused by pooling in the tracheal blind pouch in laryngotracheal separation is prevented presumably due to the slow but continuous turnover of pooling material. This result supports the validity and usefulness of laryngotracheal separation for the treatment of intractable aspiration. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To examine the presentation, mechanisms, and management of blunt laryngotracheal trauma in a pediatric population, emphasizing the rise in severity. Design: Retrospective analysis of laryngotracheal trauma evaluated from 1995 to 2008. The presentation, mechanism, management and outcomes data are detailed. Setting: Tertiary medical center. Patients: Thirty-five patients were identified with major laryngotracheal trauma. Main outcome measures: Surgical results, airway patency, voicing, swallowing and other residual disabilities are tabulated. Results: Average age was 10.8 years, with boys outnumbering girls 22–13. In cases of major trauma, mechanisms were related to motor vehicle accidents (MVAs) in seven patients. Five of 11 major trauma victims were unconscious at presentation. Definitive airway reconstruction involved laryngotracheoplasty and tracheal resection/reanastomosis. Ten of 11 remain decannulated. Conclusions: In an increasingly mobile society, major laryngotracheal trauma is occurring in a younger population. Victims of major laryngotracheal trauma may be unconscious or have other injuries that obscure airway injury, highlighting the need for vigilance. Once the airway is secured and the patient stabilized, airway reconstruction is undertaken, achieving decannulation in most patients. Hoarseness is often a lasting morbidity. [Copyright &y& Elsevier]

Objectives: Fifty-six consecutive neurologically impaired pediatric children underwent laryngotracheal separation (LTS) for acute recurrent and chronic aspiration in the last 18 years. The population demographics, indications for surgery, and comorbidities are reviewed. This study reports early and late complications and survivorship including admissions for pneumonia/aspiration. Diagnosis related group (DRGs) and work relative value units (wRVUs) were measured to document the potential benefits before and after LTS. Study Design: Retrospective review of patient charts and records in an electronic medical record during an 18 year period. Methods: Information was obtained by a chart review and utilization of the electronic medical record. Patient specific DRG and wRVU data on their hospitalizations and outpatient encounters at the Alfred I. duPont Hospital for Children of the Nemours Foundation and survival data were recorded. Data was analyzed using chi-square analysis, a two-tailed t test, and a Fisher's Exact test. Results: Laryngotracheal separation achieved complete control of aspiration in all the children. A significant reduction in the number of hospital admissions for pneumonias after surgery was noted. After LTS there was a reduced average number of DRGs per month (p < .001) as well as wRVUs. Transient fistula formation (11%) was the most common complication. No patient had his or her procedure reversed to date. Conclusion: Laryngotracheal separation is 100% effective in controlling aspiration in all of neurologically impaired children in this study, It is a valuable procedure to prolong the life of children who have intractable aspiration. After LTS, a decrease in DRGs and wRVUs reduces health care costs for these patients. Prior to LTS, all medical and surgical treatment options for aspiration should be discussed and considered, based on the extent of the child's underlying neurologic status, ability to verbally communicate, degree of upper airway obstruction, and hope of recovery of neurologic function. Laryngoscope, 2009 [ABSTRACT FROM AUTHOR]

Samson N, Roy B, Ouimet A, Moreau-Bussiëre F, Dorion D, Mayer S, Praud J-P. Origins of the inhibiting effects of nasal CPAP on nonnutritive swallowing in newborn lambs. J App! Physiol 105: 1083-1090, 2008. First published July 17, 2008; doi:10.l 152/japplphysiol.90494.2008.-The present study investigated the mechanism by which continuous positive airway pressure (CPAP) suppresses nonnutritive swallowing (NNS) during quiet sleep (QS) in newborn lambs. Eighteen full-term lambs were chronically instrumented and evenly distributed into three separate groups to determine the extent to which modulation of NNS may be attributed to stimulation of upper airway and/or bronchopulmonary mechanoreceptors. Six lambs were tracheotomized, six other lambs underwent a two-step bilateral intrathoracic vagotomy, and the remaining six lambs underwent chronic laryngotracheal separation (isolated upper airway group). Forty-eight hours after surgery, each nonsedated lamb underwent polysomnographic recordings on three consecutive days. States of alertness, NNS and respiratory movements were recorded. Results demonstrate that a CPAP of 6 cmH2O inhibited NNS during QS while administered directly on the lower airways and that bivagotomy prevented this inhibition. However, application of CPAP on the upper airways only also inhibited NNS during QS. Finally, the application of a CPAP of 6 cmH2O had no systematic effect on NNS-breathing coordination (assessed by the respiratory phase preceding and following NNS). In conclusion, our results suggest that bronchopulmonary receptors are implicated in the inhibiting effects of nasal CPAP of 6 cmH2O on NNS in all our experimental conditions, whereas upper airway receptors are only implicated in certain conditions. [ABSTRACT FROM AUTHOR]

Objectives: In children with severe physical and mental disabilities who repeatedly develop aspiration pneumonia due to intractable aspiration, laryngotracheal separation/tracheoesophageal anastomosis or laryngotracheal separation has been performed in many institutions for the prevention of aspiration, and good results have been reported. However, families sometimes show a marked reluctance to give consent to these surgical techniques because of tracheal transection. A purpose of this study is to evaluate a new surgical procedure for laryngotracheal separation without tracheal transection. Study Design: Case-series study. Methods: As a new, simple, less invasive surgical technique for the prevention of aspiration without tracheal transection, we performed tracheal closure (tracheal flap method) in six children. A U-shaped flap of the tracheal anterior wall from the 2nd to the 4th/5th tracheal ring was produced, bent toward the tracheal lumen, and sutured to the tracheal posterior/lateral walls by mattress stitches for tracheal closure. In addition, the closure was covered with a cutaneous U-shaped flap for reinforcement and a permanent tracheal stoma was constructed. Results: In all six patients, aspiration pneumonia could be prevented without severe complications. Conclusions: Tracheal closure (tracheal flap method) has effects comparable to those of other surgical techniques for the prevention of aspiration, and may be useful for aspiration prevention in children with severe physical and mental disabilities. [ABSTRACT FROM AUTHOR]

Summary: A developmentally delayed 11-year-old male developed extensive spontaneous subcutaneous emphysema 6 weeks after a laryngotracheal separation. Computed tomography demonstrated a small amount of air at the distal end of the laryngeal stump and significant esophageal air. Aerophagia was diagnosed with air presumed diverted through the laryngeal stump due to cricopharyngeal hypertension. Cricopharyngeal botulinum toxin injection was coordinated with a minimal neck dissection to drain the subcutaneous emphysema. The subcutaneous emphysema gradually improved and the patient was discharged home. His subcutaneous emphysema has not returned after four total botulinum toxin injections every 3 months. [Copyright &y& Elsevier]

Summary: Intractable aspiration is a life-threatening medical problem. There are many surgical procedures for the treatment of intractable aspiration. Our experience with three children was reported here. After failing initial conservative measures, the first two patients had supraglottic laryngeal closure performed through an endoscopic approach with a small hole left superiorly for phonation. However, both of them developed dehiscence of the closure postoperatively, necessitating a more definitive procedure to stop the aspiration. Their symptoms of aspiration were only relieved after they underwent laryngotracheal separation. In the third child, laryngotracheal separation was performed as the initial procedure and the symptoms of recurrent aspiration were relieved. In conclusion, the treatment of intractable aspiration requires a definitive procedure from the outset and we would suggest, based on literature review and on our experience, that laryngotracheal separation is the most effective and reliable option, albeit lack of phonation is inevitable. A comprehensive review of all procedures used for treatment of this condition was also undertaken. [Copyright &y& Elsevier]

Abstract: Laryngotracheal separation is a rare variant of laryngeal trauma. However it is life threatening and potentially fatal. Patients with this injury usually succumb at the site of the accident itself. Here we present two cases of laryngotracheal separation of different etiology and of different outcomes. The treatment advocated for laryngotracheal separation is initially airway stabilization followed by formal repair of the transected trachea. However both our cases illustrates that the outcomes can be different and that a long term treatment plan should be individualized to each patient. [Copyright &y& Elsevier]

Chronic aspiration is a difficult and potentially lethal problem. Patients who have persistent soilage of the upper respiratory tract despite discontinuing oral intake may be offered surgical intervention to avoid life-threatening pulmonary infections. The Lindeman procedures (tracheoesophageal diversion and laryngotracheal separation) have gained popularity as surgical treatments for intractable aspiration because of their efficacy in preventing aspiration and their technical simplicity. A major downside of these procedures is the necessity for a tracheostoma and the loss of speech following surgery. Rarely, patients recover from the neurologic deficits which led to their intractable aspiration and desire reversal of their Lindeman procedure. While few "successful" reversals have been reported, detailed accounts of the long-term results of such patients are lacking. We describe a patient who underwent a laryngotracheal separation for intractable aspiration following a brainstem stroke. In the following six months he experienced significant neurologic recovery and, after careful evaluation, underwent surgical restoration of laryngotracheal continuity. Five years later he speaks fluently and has no dietary restrictions. Videofluooroscopic examination and quantitative voice analysis reveal near-normal laryngeal function. [ABSTRACT FROM AUTHOR]

Complete laryngotracheal separation is a rare life-threatening trauma that may occur due to road traffic accidents. Unfortunately, this injury may be missed if emergency physicians were not aware of its possibility. We present a pediatric patient who had complete laryngotracheal separation and esophageal injury caused by strangulation with a headscarf while riding a four-wheeled motorcycle. The neck on external examination showed only a ligature mark without open wounds. The injury was identified while attempting tracheostomy as the patient had a decreased oxygen saturation and was aphonic. The patient underwent complete airway reconstruction and stenting as well as low tracheostomy with complete reconstruction and anastomosis of the esophagus. The patient was decannulated after a few weeks with the vocal cords in paramedian position and no aspiration. This case demonstrates that early prompt treatment can save the patient's life and result in good functional outcomes.

Impaired laryngeal protective function can result in intractable aspiration. Surgery to separate the upper digestive tract from the respiratory tract is often necessary in cases of intractable aspiration to prevent recurrent bronchopulmonary contamination and resultant complications, including death. The common surgical techniques for the prevention of intractable aspiration are presented. The results of each procedure for aspiration prevention and reversibility are compared. The advantages and disadvantages of each surgical technique are discussed. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Tracheo-innominate artery fistula (TIF) is a rare but life-threatening complication of tracheostomy. There are many reports about TIF but the mechanism of TIF formation remains poorly documented. Our objective is to investigate the TIF pathologically and suggest the possible mechanism of TIF formation. Patient and Methods: The patient was an 11-year old boy with a history of severe childhood epilepsy, cerebral palsy, and psychomotor retardation who died from TIF. We investigated the TIF histopathologically through his autopsy and reviewed bibliographical considerations. Results: Autopsy revealed massive blood aspiration from a large TIF and histopathological findings showed the following: (1) fibroepithelial polyps around the fistula; (2) squamous metaplasia of tracheal mucosa; (3) disappearance of tracheal cartilages and tracheal glands; and (4) arteritis (infiltration of neutrophils into the mesarterium and endarterium). Probably, (1) and (2) indicate chronic and repetitive irritations caused by cannula. (3) and (4) indicate intense inflammation caused by local infection. In this case, it is suggested that the chronic damage by cannula and the local infection resulted in the fistula formation and rupture of innominate artery. Conclusion: The present case suggests a pathogenesis in which chronic damage to the anterior tracheal wall by the cannula and consequent infection led to fistulation and rupture of the innominate artery. [Copyright &y& Elsevier]