Annals of Otology, Rhinology & Laryngology 117(8):574-580.

© 2008 Annals Publishing Company. All rights reserved.

Long-Term Results of Laryngeal Suspension and Upper

Esophageal Sphincter Myotomy as Treatment for
Life-Threatening Aspiration
Martijn P. Kos, MD; Eric F. L. David, MD; IJke J. Aalders;
C. Frits Smit, MD, PhD; Hans F. Mahieu, MD, PhD

Objectives: We evaluated the long-term results of laryngeal suspension and upper esophageal sphincter (UES) myotomy
in patients with life-threatening aspiration.
Methods: In the period 1995 to 2004, 17 patients with severe aspiration caused by insufficient laryngeal elevation and
absent or negligible pharyngeal constrictor muscle activity during deglutition resulting in aspiration pneumonia were
surgically treated with a laryngeal suspension procedure and UES myotomy. Preoperative and postoperative videofluo-
roscopy was performed to assess swallowing and aspiration.
Results: In 9 of the 17 patients, long-term (more than 1 year) full oral intake without aspiration was achieved. Three other
patients demonstrated improvement of deglutition with partial restoration of oral intake with adjusted food consistency,
but remained partly dependent on gastrostomy feeding for adequate nutrition. Two patients no longer had cases of aspira-
tion pneumonia, but were unable to achieve even modified oral intake. Three patients finally underwent total laryngec-
tomy — 2 of them after initial successful full oral intake without aspiration but with recurrent aspiration as a result of
progression of neuromuscular disease. None of the patients succumbed to aspiration pneumonia.
Conclusions: In most of our patients, life-threatening aspiration was successfully treated by UES myotomy and laryngeal
suspension with restoration of oral intake.
Key Words: aspiration, dysphagia, laryngeal suspension, upper esophageal sphincter myotomy.

INTRODUCTION omy is considered to be a manometrically proven

In patients with chronic aspiration and recurrent remnant of functioning hypopharyngeal activity.1
pneumonia, often a strict percutaneous endoscopic Unfortunately, in many cases of severe chronic as-
gastrostomy (PEG) feeding policy, a total laryngec- piration, this required remnant of pharyngeal activ-
tomy, or some other type of permanent anatomic or ity, which is considered essential for propulsion of
functional separation of airway and digestive tract the bolus and overcoming the remaining resistance
is performed. However, in selected cases it is pos- of the UES to open the esophageal inlet, is absent.
sible to preserve or restore oral intake with a func- Absence of pharyngeal activity is therefore consid-
tional larynx by a laryngeal suspension procedure in ered a contraindication to UES myotomy by some
combination with myotomy of the upper esophageal authors.1,2
sphincter (UES). This procedure should be consid- If we take into consideration the normal physiolo-
ered if aspiration is caused by a combination of de- gy of deglutition, there is evidence3 that the most im-
ficient deglutitive laryngeal elevation, lack of pha- portant factor responsible for opening of the esopha-
ryngeal constrictor activity, and insufficient opening geal inlet is not relaxation of the UES, nor passive
of the esophageal inlet. opening as a consequence of the propulsion of the
Upper esophageal sphincter myotomy is the most bolus being pushed downward by the peristaltic
frequently used surgical technique for treating dys- contraction of the pharyngeal constrictor muscles,
phagia and aspiration. Often, however, this proves but deglutitive laryngeal elevation (Fig 1). Because
to be insufficient to prevent aspiration. One of the the UES is attached to the larynx, anterior and crani-
important prognostic factors of a successful myot- al displacement of the larynx during the pharyngeal
From the Departments of Otolaryngology–Head and Neck Surgery (Kos, Aalders, Smit, Mahieu) and Radiology (David), Free Univer-
sity Medical Center, Amsterdam, and the Department of Otolaryngology, Meander Medical Center, Amersfoort (Mahieu), the Nether-
lands.
Correspondence: Martijn P. Kos, MD, Dept of Otolaryngology–Head and Neck Surgery, Free University Medical Center, PO Box
7057, 1007 MB Amsterdam, the Netherlands.

574
575 Kos et al, Results of Laryngeal Suspension as Treatment for Aspiration 575

A B C
Fig 1. Schematic presentation of normal deglutition. A) Oral phase of deglutition. Note low position of larynx. B) Early pharyn-
geal phase of deglutition. Note anterior and superior displacement of hyoid, and descending propulsive activity of constrictor
pharyngeal muscles. C) Late pharyngeal phase of deglutition. Note anterior and superior displacement of larynx, in protected
position under base of tongue; epiglottis tilted over laryngeal entrance; opened esophageal inlet; and pharyngeal constrictor
muscle propelling bolus in esophagus.

phase of the swallowing act results in opening of aspiration from another cause.
the esophageal inlet. Simultaneous relaxation of the
UES facilitates the opening of the esophageal inlet, Most alternative surgical procedures used for
and propulsive activity of the pharyngeal muscula- treatment of severe aspiration are associated with
ture improves the passage of the food bolus. a permanent tracheostoma and loss of normal pho-
nation. The procedures proposed include total lar-
In addition to being the most important factor in yngectomy, laryngeal closure, epiglottopexy, and
opening of the esophageal inlet, the anterior and cra- laryngeal diversion.12-18 It is our considered opin-
nial displacement of the larynx also results in other ion that for some of these patients with severe as-
mechanisms that help to protect the airway from as- piration, surgical laryngeal suspension in combina-
piration. The larynx is pulled out of the way of the tion with UES myotomy provides a less mutilating
food bolus’ path; the epiglottis is lowered over the alternative, with preservation of normal phonation
laryngeal entrance as a roof protecting the airway; and respiration without permanent tracheotomy.
and the larynx is pulled under the base of the tongue, We present 17 patients who underwent UES my-
thus providing a partial cover of the laryngeal in- otomy in combination with laryngeal suspension,
let. Such a situation can be obtained surgically by performed by the senior author (H.F.M.), for severe
means of a laryngeal suspension procedure, during dysphagia and aspiration after several efforts at ag-
which the larynx is permanently fixed in the posi- gressive nonsurgical treatment had failed.
tion that it would normally obtain during the swal-
lowing act. PATIENTS AND METHODS
Since Edgerton and McKee4 and Desprez and Patients. In the period from 1995 to 2004, 17 pa-
Kiehn5 in 1959 first described laryngeal suspension tients who were evaluated in our dysphagia clinic
as a technique for improving function after surgi- were considered eligible for laryngeal suspension
cal resection of the anterior floor of the mouth, this and a UES myotomy procedure on the basis of all
technique has been used by many surgeons6-9 as an of the following 3 factors: 1) long-standing history
integral part of major ablative surgery entailing loss of severe aspiration or choking problems; 2) failed
of the mandibular-hyoid integrity or extended partial extensive nonsurgical swallowing rehabilitation;
laryngectomy. The intent in these cases is to restore and 3) videofluoroscopic examination demonstrat-
the continuity between the laryngeal-hyoid complex ing severe aspiration as a result of severely impaired
and the mandible and/or floor of the mouth muscu- pharyngeal constrictor muscle activity and impaired
lature. This is of major importance for restoration of laryngeal elevation during the pharyngeal phase of
deglutitional function and prevention of aspiration swallowing (Fig 1B).
in such cases.
The main exclusion criteria were 1) extremely
Only a few, mostly casuistic, reports have been
poor general condition with unacceptable anesthe-
published on the use of laryngeal suspension as a
siological risk and 2) airway obstruction.
surgical treatment of severe aspiration,10,11 either as
a second-stage procedure after major ablative can- Furthermore, it became clear during the study that
cer surgery or as the main surgical option for severe severe gastroesophageal reflux should be consid-
576 Kos et al, Results of Laryngeal Suspension as Treatment for Aspiration 576

PATIENT CHARACTERISTICS
Preoperative
Preoperative Postoperative Postoperative State of Postoperative Outcome Outcome
Patient Cause of Aspiration Intake Intake Fluoroscopy LES Reflux at 6 mo at >1 y
1 OPMD Oral Oral, normal No aspiration Normal No Complete Complete
consistency success success
2 OPMD Oral Oral, modified No aspiration* Normal Yes Failure Failure, TLE
consistency
3 Myotonic dystrophy Nasogastric Oral, normal Minor Unknown No Complete Complete
TF consistency aspiration success success
4 Myositis Oral Oral, normal No aspiration Normal No Complete Complete
consistency success success
5 RTx of PEG PEG No aspiration Insufficient Yes Failure Failure
nasopharynx (aspiration of
(>10 y) refluxate),
TLE
6 RTx of Oral Oral, modified Minor Normal Yes Complete Partial
nasopharynx consistency; aspiration success success
(>10 y) later PEG
7 RTx of Nasogastric PEG Minor Insufficient Yes Failure Failure, TLE
nasopharynx TF aspiration*
(>10 y)
8 RTx of PEG Oral, modified Minor Normal Yes Complete Complete
nasopharynx consistency aspiration success success
(>10 y)
9 CNS and/or skull PEG Oral, normal No aspiration Normal No Complete Complete
base surgery + RTx consistency success success
10 CNS and/or skull Nasogastric PEG; later Moderate Normal (on No Failure Partial
base surgery TF oral, modified aspiration esophagoscopy; success
consistency no reflux)
11 CNS and/or skull PEG PEG Significant Normal Yes Failure Failure
base surgery aspiration
12 CNS and/or skull PEG Oral, normal Minor Normal No Partial Complete
base surgery consistency aspiration success success
13 CNS and/or skull Nasogastric Oral, normal Minor Normal No Complete Complete
base surgery TF consistency aspiration success success
14 Posterior pharynx PEG Oral, normal No aspiration Unknown No Complete Complete
resection + RTx consistency success success
15 Commando resection PEG Oral, modified Minor Unknown No Partial Complete
+ 2× flap consistency aspiration success success
reconstruction + RTx
16 Supraglottic PEG PEG Significant Normal No Failure Failure
laryngectomy + aspiration
partial resection of
base of tongue + RTx
17 Commando resection PEG Oral, modified Minor Normal No Partial Partial
+ flap reconstruction consistency; aspiration success success
+ RTx later PEG
LES — lower esophageal sphincter; OPMD — oculopharyngeal muscular dystrophy; TLE — total laryngeal excision; TF — tube feeding; RTx
— radiotherapy; PEG — percutaneous endoscopic gastrostomy; CNS — central nervous system.
*Eventually significant aspiration because of progressive muscular dysfunction.

ered a contraindication, as is discussed below. The metric examination failed in 2 others because the
study included 12 men and 5 women, with a mean catheter could not be tolerated. All manometric ex-
age of 55.8 years (range, 21 to 78 years). Thirteen aminations but 1 showed absent or barely noticeable
patients were unable to manage any oral intake and hypopharyngeal contractions. The only patient who
were completely gastrostomy-dependent. The other had weak but manometrically clearly definable hy-
4 had chosen to remain on oral nutrition despite sev- popharyngeal contractions first underwent UES my-
eral episodes of aspiration pneumonia. otomy, which failed to prevent the aspiration. Two
of the 14 patients showed manometric signs sug-
Preoperative manometry was performed in 14 pa- gestive of lower esophageal sphincter (LES) insuf-
tients; 1 patient refused manometry, and the mano- ficiency. Two patients had severe nocturnal episodes
577 Kos et al, Results of Laryngeal Suspension as Treatment for Aspiration 577

A B

Fig 2. Preoperative and postoperative videofluoroscopy. Asterisks — body of hyoid bone. A) Videofluoroscopic frame
shows severe aspiration in late pharyngeal phase before laryngeal suspension and upper esophageal sphincter (UES) my-
otomy. Note absent pharyngeal constrictor activity and absent laryngeal elevation. B) Videofluoroscopic frame in late
pharyngeal phase after laryngeal suspension and UES myotomy shows no aspiration. Note position of suspended larynx
and epiglottis.

of dyspnea because of aspiration of saliva. Neither hypopharyngeal manometry. In the last 7 patients,
had any oral intake. Three patients had a tracheot- preoperative 24-hour double-probe esophageal pH-
omy in the past combined with extensive head and metry was performed to exclude preexisting reflux.
neck cancer surgery. One patient presented with a Preexisting severe reflux was considered a contrain-
tracheotomy, because his swallowing problems due dication, as was concluded from the analysis of the
to muscular dystrophy became apparent after gen- earlier failed cases.
eral anesthesia for elective mandibular surgery that Outcome Measure. The outcome was considered
was combined with a tracheotomy. a complete success, a partial success, or a failure. A
The cause of the dysphagia was muscular dystro- complete success meant that a patient was able to
phy or myositis in 4 patients, muscular atrophy as a totally fulfill his or her nutritional needs by oral in-
late sequela of radiotherapy in 4 patients, intracrani- take without clinically significant aspiration. A par-
al, central nervous system and/or skull base surgery tial success meant that oral intake without clinically
in 5 patients, and extensive head and neck cancer significant aspiration was possible but not sufficient
surgery in combination with radiotherapy in 4 pa- for nutritional needs and that PEG feeding was still
tients (see Table). required for adequate nutrition. A failure meant that
there was very restricted or no oral intake possible
Preoperative and Postoperative Workup. Preoper- without aspiration.
ative assessment of the airway and pulmonary func-
tion was performed in all patients by means of chest Surgical Procedure. The surgical procedure (Fig
radiograph and pulmonary function tests, including 3) starts with a UES myotomy. This is performed
a flow-volume loop, to exclude airway obstruction. by slightly expanding the UES with an inflatable
Voice quality was assessed by means of voice range balloon or cuff in the esophageal entrance to facili-
profiles. Laryngeal function was assessed by means tate cutting even the tiniest muscle fibers, preserv-
of videolaryngostroboscopic examinations both be- ing only a thin layer of mucosa. The integrity of the
fore and after operation. mucosa is tested after severing all muscle fibers by
blowing air through the retracted tube to exclude a
The following examinations were routinely per- small perforation. All infrahyoid prelaryngeal mus-
formed regarding deglutition: preoperative and post- cles are severed to prevent traction in the caudal di-
operative videofluoroscopy (Fig 2); preoperative rection after surgery. A laryngeal suspension is per-
and postoperative functional fiberoptic evaluation formed by approximating the thyroid cartilage and
of swallowing19; and preoperative esophageal and the hyoid bone with polytetrafluoroethylene (per-
578 Kos et al, Results of Laryngeal Suspension as Treatment for Aspiration 578

A B
Fig 3. Schematic presentation of UES myotomy and la- Fig 4. View of larynx and esophageal inlet following la-
ryngeal suspension procedure. A) UES myotomy per- ryngeal suspension, obtained with 90° telescope during
formed; thyrohyoid approximation by 0-Ethibond (Eth- spontaneous respiration. 1 — Posterior surface of cricoid
icon, Somerville, New Jersey) suture tied as mattress plate; 2 — epiglottis; 3 — wide-open esophageal inlet.
suture over polytetrafluoroethylene bolsters on thyroid
cartilage and around body of hyoid bone. B) Thyrohy-
oid complex suspended from mandible by 0-Ethibond Table. The mean follow-up for all patients was 4.4
sutures, which have been passed around body of hyoid years (range, 1.8 to 8.0 years). The initial results af-
bone and through holes drilled in mandible. ter 6 months showed complete success in 8 patients,
partial success in 3 patients, and failure in 6 patients.
manent) sutures and Vicryl 0 (Ethicon, Somerville, The long-term outcome, after a follow-up period of
New Jersey; resorbable but strong enough to over- more than 1 year, was considered a complete suc-
come initial traction) tied over a polytetrafluoroeth- cess in 9 patients (53%). Seven of these patients
ylene sheet to prevent rupturing of the thyroid car- were able to have a diet with a normal consistency,
tilage and by pulling this laryngeal-hyoid complex and 2 were only able to have a diet with a modified
toward the chin by two Ethibond (Ethicon) sutures, consistency. A long-term partial success was seen in
as well as the polytetrafluoroethylene sutures, which 3 patients (18%). These 3 were only able to have an
are passed through drill holes in the mandible just oral diet with a modified consistency. Five patients
posterior to the angle of the chin and anterior to the had a very restricted or no oral intake at all, and their
foramen of the mental nerve and are then tied. To cases were considered failures in long-term follow-
prevent overcorrection and consequent airway com- up.
promise, laryngoscopy is performed just before ty-
ing the sutures to ensure that the epiglottis and the During the follow-up of patients with partial or
base of the tongue do not completely obstruct the complete success, 2 patients again developed 1 sin-
larynx. This is not always easy to estimate, because gle episode of pneumonia without obvious aspira-
at this moment the intratracheal tube is still in place, tion, which was adequately treated with antibiotics.
preventing complete obstruction of the laryngeal in- The other 10 patients have remained completely free
let. of any sign of pulmonary sequelae of aspiration.
If the patients did not already have a PEG tube,
they were given a transnasal feeding tube for the ini- Three of the 5 patients in whom the procedure
tial postoperative period. It is advisable to perform failed eventually underwent total laryngectomy.
a temporary tracheotomy to guarantee a patent air- Two of these were initially able to rely on oral intake
way in the postoperative period, because as a conse- for their nutritional needs without significant aspi-
quence of the laryngeal suspension the laryngeal en- ration, but after approximately half a year they had
trance is displaced anteriorly and cranially (Fig 4), recurrent episodes of aspiration and septicemia. Re-
interfering with intubation in case of airway com- peated videofluoroscopy was suggestive of progres-
promise. This tracheotomy should be performed at sive muscular dysfunction in both. The larynx was
the end of the procedure, after the actual laryngeal still in the elevated position, ruling out the possibil-
suspension procedure, so as not to limit the extent of ity of slipping of the sutures. One patient showed
the laryngeal suspension.20 progressive insufficiency of the velum, and the oth-
er developed problems with opening of the esopha-
RESULTS geal inlet without evidence of mechanical obstruc-
An overview of the results is presented in the tion on pharyngoesophagoscopy.
579 Kos et al, Results of Laryngeal Suspension as Treatment for Aspiration 579

Of 6 patients who had postoperative signs of re- be completely obstructed. Initially, this obstruction
flux, only 2 had shown preoperative manometric was considered to be a consequence of postopera-
signs suggestive of LES insufficiency. These 2 cases tive swelling, but when after 2 weeks the patient was
are both considered failures, and the patients eventu- still unable to speak or block her cannula, revision
ally underwent total laryngectomy. In 1 of them lar- surgery was performed by slightly loosening the su-
yngectomy had to be performed, despite a markedly tures between the thyroid and hyoid cartilages. After
improved pharyngeal phase of swallowing after la- this revision, she underwent successful decannula-
ryngeal suspension and UES myotomy, because the tion and regained normal phonation.
patient repeatedly had aspiration pneumonias from
secondary aspiration following gastroesophageal re- DISCUSSION
flux. Postoperative videofluoroscopy excluded pri- First of all, it should be realized that this is a small
mary aspiration. Furthermore, the aspiration pneu- study with a very diverse patient group who had as-
monias recurred despite prolonged periods of strict piration from a variety of different causes. This sce-
PEG feeding, suggesting secondary aspiration from nario obviously limits the conclusions that can be
gastroesophageal reflux. In this particular case, the extracted from our observations. Nevertheless, all
preoperative history had been negative for gastro- patients demonstrated severe impairment of pharyn-
esophageal reflux, but preoperative manometry of geal constrictor muscle activity and impairment of
the LES had shown abnormally low LES pressure laryngeal elevation as the main cause of severe aspi-
over a short segment. One of the 2 other patients ration, irrespective of the underlying cause. The fact
who eventually underwent total laryngectomy also that patients with such severe swallowing disorders
showed preoperative manometric signs suggestive are rare excludes the possibility of systematic study
of LES insufficiency. in a larger and more homogeneous group.
Two of the 5 patients in whom the procedures Various surgical procedures have been described
failed over the long term did not undergo total lar- to deal with life-threatening aspiration. None of
yngectomy. Although they tolerated no more than a these studies have included large numbers of pa-
very restricted oral intake, they found the laryngeal tients. Most procedures entail a permanent separa-
suspension and UES myotomy to be an improve- tion of airway and food passage, resulting in func-
ment in the sense that they no longer aspirated sali- tional deficits, eg, permanent tracheostomy and/or
va. Both had PEG feeding. One of these patients had loss of voice. Another procedure, which does not
previously undergone extended horizontal laryngec- separate the airway and food passage and enables
tomy with partial base-of-tongue resection and post- normal phonation, is modified epiglottoplasty. How-
operative radiotherapy. Although the esophageal ever, in this procedure tracheostomy is needed to en-
inlet was widely opened in this patient, aspiration sure a sufficient airway.21
persisted because of the lack of tissue bulk in the
base of the tongue. Augmentation of the base of the The goal of the laryngeal suspension and UES my-
tongue was performed, but unfortunately, it did not otomy procedure is not to normalize the swallowing
improve the swallowing act. act, but to prevent life-threatening aspiration with
preservation of a functional larynx. Even patients
In 12 patients, preoperative and postoperative who were not able to obtain sufficient oral intake
voice range profiles were determined and showed after the procedure had fewer problems with aspira-
no significant difference in dynamic or melodic tion. The voice quality does not seem to change after
range. In 3 patients, after 1 month in 2 of them and elevation of the larynx. Because of potential post-
3.5 years in the other, a second myotomy had to be operative airway compromise and anticipated diffi-
performed to further improve deglutition. culties with intubation as a result of the displaced
All temporary tracheotomies were closed within larynx, elective temporary tracheotomy is nowadays
5 weeks, with the exception of 2 patients who under- routinely performed in all patients.
went decannulation after 1 and 4 years, after correc- Especially in patients who, because of a loss of
tion for their preexistent impaired laryngeal mobil- sensation, did not notice their aspiration (silent aspi-
ity. Both had neurosurgical causes of aspiration. ration) before the operation, the postoperative situa-
In 1 patient, the laryngeal suspension was over- tion can be disappointing, because the propulsion of
corrected initially. At the laryngoscopic examination the food bolus is still not normalized. These patients
during the procedure, it was estimated that sufficient fail to notice the improvement with respect to the as-
space would still be available between the epiglottis piration. It is, of course, essential to extensively in-
and the arytenoid cartilages, but during the postop- form the patient before the operation of the expected
erative examination, the laryngeal inlet was seen to outcome of the procedure. For these patients with a
580 Kos et al, Results of Laryngeal Suspension as Treatment for Aspiration 580

loss of sensation, perhaps the option of additional didates for the procedure. To avoid unrealistic ex-
restoration of sensation by neural anastomosis can pectations, patients should be made to understand
be helpful in the future.11 that the goal of the surgical procedure is to prevent
It seems advisable to include LES manometry in aspiration, and not to improve the swallowing act it-
the preoperative diagnostic workup to rule out the self. Normal deglutition will never be obtained.
possibility of an insufficient LES, since severe reflux
is considered a contraindication to laryngeal suspen- CONCLUSIONS
sion. After laryngeal suspension and UES myotomy, Laryngeal suspension combined with UES my-
preexisting reflux can become worse, because this otomy can be considered a reasonable alternative
procedure abolishes the protective function of the to total laryngectomy or laryngeal diversion proce-
UES against reflux. This situation can lead to severe dures in a selected group of patients with severe as-
aspiration of gastric refluxate, even in those cases in piration problems. Most of our patients were able to
which the laryngeal suspension and UES myotomy restore oral intake with a normal diet without clini-
allows relatively safe oral intake. cally significant aspiration, but some needed a diet
All patients who are eligible for this type of sur- with a modified consistency and/or additional PEG
gery have severe dysphagia and intractable aspi- feeding to fulfill their nutritional needs. All patients
ration despite intensive previous nonsurgical, and had less aspiration of saliva.
sometimes also surgical, treatment. Laryngeal sus- Overt gastroesophageal reflux and other signs of
pension should be considered a procedure that can LES insufficiency should be considered absolute
only partly compensate for the functional degluti- contraindications to laryngeal suspension and UES
tive deficiency and thus hopefully prevent aspira- myotomy. This type of surgery will result in a per-
tion. Patients who are unable or unwilling to accept manently opened esophageal inlet, which will facili-
these uncertainties in the outcome are not good can- tate the aspiration of gastric contents.
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