K. Robert Shen
INDICATIONS
A rare late complication of tracheostomy is persistence of a stoma 3 to 6 months after removal of the tracheostomy tube. The frequency of this complication ranges widely from 3.3% to 29%. A persistent tracheal stoma usually develops when the tracheostomy tube has been left in position for a prolonged period, permitting epithelialization between the skin and the tracheal mucosa. Kulber and Passy have reported that a fistula does not develop when the period of cannulation is less than 16 weeks, but the incidence increases to 70% when the cannulation period is greater than 16 weeks. Patients who are malnourished, have been on high doses of steroids, or who have had infection around the stoma are particularly at risk for developing this complication. Granulomatous disease, prior radiation treatment, and distal obstruction such as bilateral vocal cord paralysis or tracheal stenosis are other risk factors.
When the tracheostomy tube is removed, the fistula lumen often rapidly narrows down to a dry fistula tract with inverted skin edges, but then it fails to improve further and close. When the epithelial-lined tract has formed from the trachea to the skin, the opening will persist although wound contracture might result in a significant narrowing of the orifice. Although less morbid when compared with some of the other late complications of tracheostomy such as a tracheoesophageal fistula or tracheal stenosis, persistent tracheal stomas are nonetheless troublesome. Patients may suffer from recurrent aspiration with resulting respiratory infection and ineffective cough and clearance of respiratory secretions. Unsatisfactory phonation, skin irritation and breakdown from chronic exposure to oral secretions, and intolerance to submersion also provide clear indications for surgical correction.
CONTRAINDICATIONS
Need for ongoing mechanical ventilatory support
Moderate or severe tracheomalacia
Chronic cough or recent upper respiratory tract infection
Need for endotracheal suctioning to maintain pulmonary toilet
Decannulation of tracheostomy in the previous 3 to 6 months
PREOPERATIVE PLANNING
It is essential to perform direct laryngoscopy and bronchoscopy before an attempt is made to close a persistent tracheal stoma to evaluate and rule out other tracheal pathology such as bilateral vocal cord paralysis, tracheomalacia, tracheal stenosis, or distal airway obstruction such as peristomal granulation tissue.
Determine with bronchoscopy whether the patient would have a difficult intubation. Failure to do so may result in unexpected respiratory arrest, or need for placement of emergent tracheostomy tube.
SURGERY
Techniques
A simple one-stage method of closure has been described that immediately provides an epithelialized internal surface of the trachea. A circular incision is made around the stoma, raising the margins of the flap but not sufficiently to destroy the blood supply (Fig. 41.1). This ring of tissue is then inverted and the stoma is closed with a running subcuticular suture of fine catgut (Fig. 41.2). The epidermal surface of this circular flap provides a smooth lining inside the trachea, which creates a fully epithelialized inner tracheal surface at the outset without significantly compromising the tracheal lumen. The subcuticular suture used to approximate the first layer of the closure prevents intrusion of suture material into the tracheal lumen and minimizes the change of developing intratracheal granulations. The skin and platysma on the outside of the original incision are then mobilized, with lateral extension of the incision as required. The strap muscles are freed and approximated in the midline to fill any defect. The platysma is sutured transversely over the stomal closure and the skin is also closed horizontally using subcuticular sutures to create a three-layer reconstruction (Fig. 41.3). The use of a full-thickness skin flap inhibits late contraction of the closure.
Before undertaking operative closure of a persistent tracheal stoma, Lawson and Grillo stress several important points. First, it must be established that enough cartilaginous ring structure is intact to support an anterior soft tissue bridge without respiratory embarrassment. If sufficient tracheal circumference is not available, a more complex reconstruction is necessary. Second, the airway above the tracheal stoma needs to be evaluated by roentgenograms and direct visualization with rigid bronchoscopy to rule out obstruction caused by stenosis or granulomas.
Figure 41.1 A circular incision is made around the stoma, and the edge of the skin is elevated, basing it on the stomal margin. Lateral extensions are made to mobilize skin and platysma for horizontal closure.
Figure 41.2 After the central circular flap is elevated, the stoma is closed longitudinally with a subcuticular suture. The epithelial surface is inverted toward the tracheal lumen. The strap muscles are visible laterally.
An alternative surgical technique that emphasizes the need to interpose viable muscle or skin flaps between the skin and tracheal suture lines to successfully close the persistent tracheostomy stomas has been described by Bishop. In this technique, an elliptical incision is made around the tracheostomy stoma (Fig. 41.4). The incision is carried through skin and subcutaneous tissue, elevating a superiorly based skin flap from the lower portion of the tracheostomy site. This skin flap can then be inverted and sutured to the superior rim of the stoma (Fig. 41.5). Muscle is then placed over this skin flap and sutured with multiple interrupted sutures. There are several options for fashioning muscle flap depending on the size of the defect and the amount of dead space to be closed. The strap muscles are adjacent and anterior to the trachea and can provide bulk to an area that is deficient of tissue. The sternohyoid muscle is a flat muscle that can be easily mobilized and rotated without injury to its nerve supply. The sternohyoid can be divided at a point below the tracheostomy stoma and transposed over the defect. If the defect is large, bilateral sternohyoid muscle flaps can be rotated medially (Fig. 41.6). The skin edges are then excised as an ellipse and closed in a transverse direction (Fig. 41.7).
Figure 41.3 Cross-sectional view of reconstruction. The line of circumscription is indicated. In the lower panel, the epithelialized flaps have been sutured vertically on the dermal side, and the platysma and skin have been closed in the opposite direction.
Figure 41.4 An elliptical incision is made around the tracheostomy stoma.
Figure 41.5 A superiorly based skin flap is inverted and sutured to the superior rim of the stoma.
Figure 41.6 A: The sternohyoid muscle is mobilized and divided. B: The sternohyoid muscle is rotated medially over the defect and sutured.
Figure 41.7 The skin edges are excised in an ellipse and closed with a subcuticular stitch in a transverse direction.
To avoid the complications sometimes associated with techniques of direct or flap closure of large tracheocutaneous fistulas such as pneumothorax or respiratory compromise, Drezner and Cantrell recommend an alternative closure technique. They recommend the use of this technique in patients when the defect of the anterior tracheal wall is greater than or equal to 4 mm in diameter. The tracheocutaneous fistula and scar are excised using a horizontal elliptical excision. The fistula is then dissected down to the anterior tracheal wall and divided. A small metal tracheostomy tube (no. 3 or no. 4 modified Jackson; Pilling Company, Fort Washington, PA) is inserted into the tracheostomy site. The strap muscles are elevated and closed in the midline around the tracheostomy tube using 4-0 polyglactin (Ethicon Inc., Somerville, NJ) suture. The skin edges are widely undermined and then closed around the tracheostomy tube using simple interrupted or vertical mattress sutures of 5-0 nylon. The tracheostomy tube is capped in the recovery room or on the first postoperative day and is then removed on the second postoperative day. The small central area is then taped closed and allowed to heal by second intention. The sutures are removed on postoperative days 5 to 7. Complete excision of the fistula avoids remnants of squamous epithelium. The strap muscles are sutured in the midline and the skin edges are undermined and sutured closed to prevent recurrence of the fistula. The tracheostomy tube prevents pneumomediastinum and pneumothorax by allowing air to easily escape until the tissue planes seal.
POSTOPERATIVE CARE
Attempts should be made to wake the patients up immediately after closure and extubated in the operating room.
The patient is started on a clear liquid diet the first postoperative day and advanced to their home diet as tolerated.
COMPLICATIONS
One significant complication when performing surgery to close a persistent tracheal stoma is the development of subcutaneous cervicofacial emphysema, pneumomediastinum, and pneumothorax due to the escape of air from the trachea into the subcutaneous tissues. The risk of this complication can be decreased by extubating the patients in the operating room once they are fully awake to avoid paroxysmal coughing.
CONCLUSIONS
Prolonged presence of a tracheostomy tube can result in a failure of spontaneous closure and the development of a persistent tracheal stoma. Although a rare complication of tracheostomy, a persistent tracheal stoma is frequently the source of significant morbidity for the patient and is an indication for surgical repair. A number of techniques are available to achieve closure. Early extubation in the operating room can help prevent the development of the complication of air leaking into the soft tissues after closure.
Recommended References and Readings
Bishop JB, Bostwick J, Nahai F. Persistent tracheostomy stoma. Am J Surg. 1980;140(5):709–710.
Drezner DA, Cantrell H. Surgical management of tracheocutaneous fistula. Ear Nose Throat J. 1998;77(7):534–537.
Gilmore BB, Mickelson SA. Pediatric tracheotomy. Otolaryngol Clin North Am. 1986;19(1):141–151.
Gallagher TQ, Hartnick CJ. Tracheocutaneous fistula closure. Adv Otorhinolaryngol. 2012;73:76–79.
Lawson DW, Grillo HC. Closure of persistent tracheal stomas. Surg Gynecol Obstet. 1970;130:995–996.