Aspiration can be a very vexing problem for both the surgeon and the patient, and can lead to failure and significant patient morbidity even when the underlying stenosis has been corrected. Besides unilateral and bilateral vocal cord paralysis, all of the following may contribute to aspiration: loss of sensation from superior laryngeal nerve injury, old age, superior laryngeal release procedures, and cricopharyngeal muscle spasm from denervation, chronic tracheostomy tube use ("trach dominance"), and a fixed partially stenotic glottis. As we age, we lose laryngeal sensation and do not feel aspirated liquids in the larynx and trachea as well. Injury to the superior laryngeal nerve also decreases sensation. After a superior laryngeal release, the larynx is dropped down away from the epiglottis, so the epiglottis does not protect the larynx to the same extent. With cricopharyngeal spasm, swallowing is more difficult, and food and liquid tend to spill over into the larynx. Cricopharyngeal muscle spasm can be improved by inferior constrictor myotomy. Vocal cord paralysis implies that a segment of the laryngeal introitus does not move normally and to some figure 35-8 Montgomery thyroplasty implant in place, medializing the vocal cord.

degree predisposes to aspiration. This can become manifest after a chronic obstructive stenosis has been surgically corrected. A preoperative barium swallow can help detect occult preoperative aspiration so as to forewarn the surgeon that postoperative aspiration may become a problem. Unilateral vocal cord paralysis with associated aspiration can be improved with vocal cord medialization, as noted above. Swallowing training and rehabilitation by a speech pathologist can often overcome the aspiration problems of the aging and those with loss of laryngeal sensation. The patient is taught techniques of swallowing, following each swallow with a little cough to clear any aspirated material. Trach dominance refers to patients who lose laryngeal function as a result of chronic diversion of airflow away from the laryngeal lumen, as in a patient who has an unvalved tracheostomy chronically. Laryngeal function, including the protection from aspiration, slowly degrades in the setting of a chronic tracheostomy tube. Similarly, patients with a chronic, significant glottic level stenosis also are deprived of normal laryngeal airflow and can develop a type of disuse atrophy which may require aggressive speech and swallowing therapy post corrective stenosis surgery. All these problems are obviously much more difficult when dealing with infirm, aged, and mentally slow patients in whom gastrostomy may be necessary to provide ongoing nutrition. Vocal cord paralysis, due to neurologic problems such as stroke or amyotrophic lateral sclerosis, often requires a tracheostomy with a cuffed tube. Over the long term, glottic closure by bilateral medialization thyroplasty or a laryngofissure procedure with suturing together of the denuded vocal cords can be necessary. This, of course, requires a permanent tracheostomy and eliminates normal speech; loss of speech is often of little importance in these patients, who are typically aphonic.

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