# Aerodigestive & Esophageal Surgery: Aspiration in TEFs — GCMD Library

Dr. Michael Rutter moderates a discussion of tracheal esophageal fistula, aspiration, aspiration testing, and esophageal reflux.

Type: video · 5 min · posted 2019-01-11
Canonical: https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039

## Chapters
- [0:00](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=0) Framework for Aspiration: Causes and Management
- [2:34](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=154) Testing for Food and Drink Aspiration
- [4:10](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=250) Testing for Saliva and Reflux Aspiration

## Statements
- "Most children who aspirate have a functional or neurological problem" (clinical) [0:10](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=10)
- "Cerebral palsy and CHARGE syndrome are examples of functional/neurological causes of aspiration" (clinical) [0:16](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=16)
- "Anatomical problems causing aspiration include tracheoesophageal fistula and laryngeal cleft" (clinical) [0:22](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=22)
- "Bad pharyngeal scar can cause aspiration in some children" (clinical) [0:34](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=34)
- "Esophageal stenosis with backup and spillover can cause aspiration" (clinical) [0:39](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=39)
- "Nasogastric tube or gastrostomy tube can be considered for children who aspirate food and drink" (clinical) [0:53](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=53)
- "Robinul (glycopyrrolate) generally does not work for managing saliva aspiration" (opinion) [1:13](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=73)
- "Botox to major salivary glands is a temporary solution and a good test run for how a child would cope with less saliva" (clinical) [1:19](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=79)
- "Drool procedure involves removing submandibular glands and ligating parotid ducts" (clinical) [1:30](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=90)
- "Tracheotomy allows suctioning the airway clear of secretions" (clinical) [1:38](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=98)
- "BiPAP on a tracheostomy blows secretions up and out of the mouth" (clinical) [1:45](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=105)
- "Laryngotracheal separation is the only guaranteed operation to stop aspiration" (clinical) [1:53](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=113)
- "Laryngotracheal separation is not commonly done because you lose your ability to vocalize" (clinical) [2:02](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=122)
- "Nissen fundoplication or any sort of fundoplication may assist with gastroesophageal reflux aspiration" (clinical) [2:09](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=129)
- "GJ tube may assist with gastroesophageal reflux aspiration" (clinical) [2:09](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=129)
- "Tight fundoplication with non-motile esophagus can cause accumulation and spillover of esophageal contents" (clinical) [2:21](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=141)
- "In children with tracheostomy, putting colored dye in the mouth and checking if it comes out the trach tube is the simplest test for aspiration" — Bob (clinical) [2:55](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=175)
- "Dye test can be done at home in a normal setting and repeated" — Bob (clinical) [3:05](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=185)
- "Dye test is helpful to convince skeptical parents that the child is aspirating" — Bob (opinion) [3:10](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=190)
- "Video swallow studies and endoscopic swallow studies can be useful for testing aspiration" — Bob (clinical) [3:18](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=198)
- "There are no unequivocal endoscopic markers of aspiration" — Bob (clinical) [3:23](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=203)
- "Lipid-laden macrophages are non-specific markers of aspiration" — Bob (clinical) [3:35](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=215)
- "Recovery of lipid-laden macrophages depends on what material was aspirated, how much lipid it contained, the amount aspirated, and time since aspiration" — Bob (clinical) [3:35](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=215)
- "Lots of lipid-laden macrophages in the right clinical setting is convincing evidence of aspiration, but not a black and white yes/no answer" — Bob (opinion) [3:57](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=237)
- "Green food dye is preferred for dye testing because it is not a natural body color" (clinical) [4:24](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=264)
- "Nuclear medicine scan with radioactive tracer on tongue can detect saliva aspiration in patients without tracheostomy" (clinical) [4:35](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=275)
- "No reflux testing methods are particularly good markers for aspiration" — Phil (opinion) [5:02](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=302)
- "Multi-channel intraluminal impedance testing has mostly replaced simple pH testing for detection of reflux" — Phil (clinical) [5:08](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=308)
- "Impedance testing does not add anything to the diagnosis of aspiration itself" — Phil (clinical) [5:08](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=308)
- "Impedance testing tells you whether something is being delivered from the stomach to the esophagus, but not what happens to it after that" — Phil (clinical) [5:21](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=321)

## Transcript
But we're gonna start off with tracheoesophageal fistulas, and the framework of how to think about children who aspirate. Most children who aspirate, have a functional or neurological problem. They've got cerebral palsy, they've got CH syndrome. Some children have an anatomical problem. And so the anatomical problems could be the obvious, the tracheoesophageal fistula or a laryngeal cleft. In some children, they've got a bad pharyngeal scar. In some children, you might have esophageal stenosis with backup and spillover. And so the next aspect to grasp is what can you aspirate. And so the obvious is food and drink. And what can you do about that? You could consider a nasogastric tube or a gastrostomy tube. The next group of children who aspirate their saliva. And again, there's a lot of different things that we can do to help manage those children. Something as simple as medication like Robinul. Generally, it doesn't work, but you can try it. Uh, we can Botox the major salivary glands, a temporary solution, but it's a good test run for how a child would cope with less saliva. We quite frequently do a drool procedure. We remove the submandibular glands and ligate the parotid ducts. If necessary, you can place a tracheotomy. It allows you to suction the airway clear of secretions. You could put BiPAP on a tracheostomy, so that any secretions are blown up and out of the mouth. And if you truly want to stop aspiration, there's only one guaranteed operation, which is a laryngotracheal separation. Which is not something that is commonly done because you lose your ability to vocalize. The other things that you can aspirate a reflux, gastroesophageal reflux, and again, a Nissan fundoplication or any sort of fundoplication may assist with that, or even a GJ tube. And very occasionally we'll see a child who aspirates their esophageal contents. Tight fundoplication, non-motile esophagus, you can get accumulation and spillover. And so testing, how can we test for the different sorts of aspiration? And so this is firstly a question to the panel. Uh, what are your preferences if you're trying to test for aspiration for, say, food and drink? I think we'll start off with the pulmonologist here, Bob. Well, obviously it depends on the, the child. Uh, if a child has a tracheostomy, the simplest test is to put some colored dye in his mouth and see if it comes out of his trach tube. That's something you can do at home in a normal setting and do repeatedly. It's also very helpful to convince skeptical parents that the child actually is aspirating because sometimes we have a lot of trouble with that. Uh, video swallow studies or endoscopic swallow studies can also be very useful. Uh, Endoscopically, one of the things that we look for is direct evidence of aspiration, and unfortunately there are no unequivocal markers of aspiration. We talk about lipid-laden macrophages, but they are not only non-specific, but the recovery of lipid-laden macrophages depends on what material was aspirated, how much lipid did it contain. The amount that was aspirated and more importantly, how long it's been since the aspiration event took place. If we see lots and lots of lipid laden macrophages in the right clinical setting, we say, yeah, this is convincing evidence that the patient is aspirating, but it's certainly not a black and white yes no answer. And if we move into saliva, Again, what are the things we can do if you've got a tracheotomy, you can again, as Bob said, do a dye test, a drop of green food dye on the tongue, and see if it comes out the trach tube. Uh, green is a great color because it's not natural, red, blue, other colors, you might confuse it with something that the body actually produces, but green's pretty characteristic. And if you don't have a tracheotomy, Again, you may have to look at whether a nuclear medicine scan is necessary, a drop of something radioactive on the tongue and see if it ends up in the lungs or the stomach. And of course, gastroesophageal reflux, and I think we'll pass that one on to Phil. There's a variety of interesting things there. Are you a believer in any of them, Phil? As a marker for aspiration, none of them are particularly good, um. Multi-channel intraluminal impedance testing is mostly replaced simple pH testing for the detection of reflux, um, but it doesn't add anything to the diagnosis of aspiration itself. It tells you whether something is being delivered from the stomach of the esophagus, but not what happens to it after that.

---
Not medical advice · citation policy: https://library.globalcastmd.com/ai