The most frequent anatomic situations which must be treated are:

These situations can cause bolus inhalation, which is mostly intra-deglutitive, on account of an alteration in the pharyngeal phase of swallowing ¹, but, sometimes, pre-deglutitive aspiration occurs, caused by an alteration in the oral phase or post-deglutitive aspiration, mostly due to an alteration in the oesophageal phase. The latter is due to spasm of the crico-pharyngeal sphincter, which prevents the entering of bolus into the oesophagus, with consequent stagnation in the pyriform sinuses. This stagnation leads to a post-deglutitive inhalation of bolus if the glottic sphincter is not working well. The problem of the crico-pharyngeal sphincter spasm is not easy to solve, as gastric-oesophageal-pharyngeal reflux is often present in these patients; relaxation of the crico-pharyngeal muscle could be achieved by means of myotomy ² or a botulinum toxin injection into the crico-pharyngeal muscle ³, but the consequence is lack of protection of the lower airways from acid or alkaline reflux, as the neoglottis is not a valid protective sphincter. Myotomy or infiltration of the crico-pharyngeal muscle with botulinum toxin should be performed only in those patients for whom the presence of gastro-oesophageal reflux has been totally excluded.

Surgical approaches for the treatment of dysphagia can be performed through an external or endoscopic approach.

External surgery techniques:

Endoscopic approaches:

The reabsorbable materials mainly used are: autologous fat, bovine collagen. The latter is preferred to fat, in most cases, as a fine needle can be used which is fundamental when the laryngeal mucosa is thin and adheres to the cartilage; otherwise hyaluronic acid can be employed. The most used non-reabsorbable material is polydimethylsiloxan (PDMS, Vox Implants^®) which is preferred to reabsorbable materials on account of its stability in time ¹⁰, but it must be used no sooner than 2 years after oncological treatment. This material is injected preferably through microlaryngoscopy, under general anaesthesia, since it may fall into the lower airways and, if so, in this way removal is easier. The injection points are:

Following supraglottic horizontal laryngectomy, the injection points are the middle third of the vocal fold in cases of atrophic vocal folds and the posterior third of the vocal fold in cases of unilateral laryngeal paralysis ⁹; in cases of bilateral paralysis of the vocal folds injection laryngoplasty is not recommended, while the recommended surgical procedures are those improving breathing without having a negative effect upon swallowing.

Fat can be removed by means of lipo-aspiration from the sub-cutis of the peri-umbilical region, using a 10 cc disposable autostatic syringe, connected via luer-lock to a 14 Gauge needle for thoracenthesis. Prior to this step, a vasoconstrictor solution is injected into the peri-umbilical region (to reduce blood in the fat sample and to prevent ruise). With “come and go” movements two syringes of 10 cc are filled. Then the needle is removed from the syringe and substituted by a luer-lock plug; the syringe is centrifuged at 3000 turns per minute, for 3 minutes, as described by Coleman ¹¹. This procedure separates fat from blood; then blood is eliminated and the concentrated fat is placed in a 5 cc luer-lock syringe with a three-way joint. Contact of the fat with air, during the transfer from one syringe to another, must be avoided, in order not to cause oxidation of the fat. The 5 cc syringe can be directly linked to the endoscopic needle or inserted into a high pressure injection pistol (Fig. (Fig.2),2), offering better control of the injection procedure.

It is always necessary to inject a double quantity of fat in order to correct glottic or neoglottic insufficiency, as part of the injected fat (from 30% to 70%) is reabsorbed.

For injection of collagen and hyaluronic acid, a thinner needle can be used (Fig. (Fig.1),1), which is linked to the high pressure syringe, in which the material is placed using a three-way circuit.

It is very important to make a slow and gradual injection, as the material must fill only the chosen point of injection, without lacerating the mucosa with consequent extrusion of the material into the airways.

Surgical approach through fiberendoscopy is performed under local anaesthesia with vaporization of 10% lidocaine into the nose and the pharynx and with instillation of 4% and 10% lidocaine into the larynx. The local anaesthetic is also added to the solution used for subcutaneous infiltration into the site of fat withdrawal. Light sedation with 2-3 mg of Midazolam can be performed intravenously. This technique, called “fiberendoscopic phonosurgery” (FEPS), has been proposed by the CELF group of Santander ¹³ and developed in Italy ^{6–8 12} with the setting up of specific instrumentation. We use a fiberoptic endoscope with a 2 mm working channel, where endoscopic instruments such as needles, forceps and scissors are inserted. Fiberoptic endoscopes are now substituted by high definition flexible digital endoscopes, with a distal chip camera, which offers high quality images, as in microlaryngoscopy; in these endoscopes, the optic fibers bring only the light to illuminate the visual field. For fat injection, we use a 19 Gauge endoscopic needle 80 cm in length, within a plastic catheter which prevents damage to the endoscope ^{6–8 12 14}. For collagen or hyaluronic acid injection, a 23 Gauge needle, 80 cm in length, is used. The endoscopic needle is linked to the high pressure syringe (Fig. (Fig.2)2) manoeuvred by the second operator.

The advantages of the fiberendoscopic, compared to the microlaryngoscopic, procedure are:

All patients were males, aged between 43 and 78 years.

The surgical technique performed was: