Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

572
Section 7
Trachea and Mediastinum
A
B
Figure 67-12. While the larynx is visualized with the laryngoscope
held in the left hand, the bronchoscope is inserted behind the epi-
glottis to the level of the vocal cords with the right hand.
Figure 67-13. The operator’s view is now directed down the shaft
of the bronchoscope. The laryngoscope is removed, and the left hand
is placed on the upper teeth to support the bronchoscope.
Figure 67-14. With the tip of the bronchoscope behind the epiglot-
tis, the initial view (A) will show both the right and the left vocal cords.
This is not the correct position to advance the bronchoscope into the
trachea. The bronchoscope is rotated 90 degrees clockwise so that
the leading tip of the beveled end is to the right lateral side. The
entire bronchoscope is shifted laterally to expose the left vocal cord
(B). With this exposure and this orientation, the bronchoscope may
be advanced safely into the trachea without causing trauma to the
right vocal cord. The left vocal cord will slide along the bevel and be
pushed laterally as the bronchoscope enters the trachea.
the telescopes beyond the end of the bronchoscope and
injuring the airway.
Working instruments should be matched to the
diameter and length of the bronchoscope. An array of
suction tubes, biopsy forceps, and different styles of
foreign body forceps should be readily available.
Communication and cooperation between the
anesthesiologist and surgeon are essential for safe ven-
tilation during a rigid bronchoscopic procedure. Stan-
dard positive pressure ventilation is the easiest method
and requires no additional equipment. This method,
however, is limiting to the surgeon and requires main-
tenance of a closed system, thus minimizing time for
the insertion of instruments and working in the distal
airway. With positive pressure ventilation, there will
always be a signifi cant air leak around the broncho-
scope such that high gas fl ow is required in the ventila-
tion circuit. This is particularly troublesome when
examining the proximal trachea because the side holes
of the bronchoscope may be above the larynx. High-
frequency jet ventilation is greatly preferable for rigid
bronchoscopic procedures but requires that the anes-
Figure 67-15. The bronchoscope has been advanced past the
larynx into the trachea for distal tracheal examination. It is of great
importance at this point that the upper hand be placed in fi rm posi-
tion to protect the teeth and upper jaw from pressure from the
bronchoscope. The bronchoscope should rest on the left thumb and
not against the teeth; this is a position similar to an open bridge, as
used with a cue stick for shooting billiards.
thesiologist be familiar with the technique. This tech-
nique does not require a closed system, and any air leak
is inconsequential. Jet ventilation can be directed
through a port on the proximal end of the broncho-
scope. If it is anticipated that the bronchoscope will
need to be repeatedly inserted and removed during the
procedure, a fl exible catheter can be inserted through

Chapter 67
Bronchoscopy and Tracheoscopy
573
the larynx and into the trachea beside the broncho-
scope (Fig. 67-16).
Foreign Bodies
Management of foreign bodies is a discipline unto itself.
Advances
in
instrumentation
have
dramatically
enhanced the safety and effi cacy of these diffi cult and
often risky procedures. As a result, current standards
of care suggest that foreign body removal should be
referred to centers with specifi cally trained staff and
appropriate instrumentation. The use of forceps with
an attached telescope (so-called optical forceps)
increases the ability to visualize and retrieve foreign
bodies. Various sizes of bronchoscopes, forceps, and
other related paraphernalia should be available in any
center performing foreign body removal (Fig. 67-17).
Because foreign bodies are most commonly encoun-
tered in children, the centers most likely to have this
type of equipment are children’s hospitals or larger
hospitals with active pediatric departments. A few
caveats useful in the management of foreign bodies are
included in Table 67-2.
Although rigid bronchoscopy is the standard for
removal of foreign bodies, there is increasing experi-
ence in retrieving foreign bodies from the airways with
fl exible bronchoscopic instrumentation. Foreign body
extraction with a fl exible bronchoscope requires
Jet ventilator
Figure 67-16. A fl exible nasotracheal suction catheter placed in
the trachea alongside the bronchoscope can be used for jet ventila-
tion. When a complex bronchoscope procedure requires removal
and reinsertion of the bronchoscope, this method allows continued
ventilation when the bronchoscope has been removed.
A
B
Figure 67-17. A, Foreign body forceps for use with a rigid bron-
choscope. The jaws are individually designed for grasping different-
shaped objects. B, Many foreign bodies, such as teeth, are too large
to remove through a rigid bronchoscope. They should be secured
against the opening of the bronchoscope and the bronchoscope and
tooth removed in unison. The bronchoscope will help protect the
larynx from injury by the tooth on removal.
Table 67-2
CAVEATS IN THE MANAGEMENT
OF TRACHEOBRONCHIAL
FOREIGN BODIES
1. Ensure that all instrumentation is available and
functioning before inducing anesthesia.
2. Correct instruments are mandatory. Biopsy forceps
are not adequate substitutes for foreign body forceps.
A variety of sizes, shapes, and grasping surfaces should
be available.
3. Perform a “dry run” with a similar foreign body to test
the various methods of grasping, twisting, and retrieving
the object. A box of variously sized nuts, dried carrot
pieces, pins, and tacks should be kept with the
endoscopy instrumentation.
4. Ensure that the anesthesiologist is adequately skilled
in the management of children undergoing
bronchoscopy. This factor alone may require transfer of
patients to a facility better equipped to handle the
procedure safely.
5. Foreign body retrieval is inherently more diffi cult
from the left side. When a left-sided foreign body has
been grasped, rotating the child so that the right side is
down may help drop the foreign body into the right
lower lobe should it be lost during retrieval.
6. During foreign body retrieval, the foreign body
should be pulled back to the bronchoscope and both the
bronchoscope and forceps removed en bloc. This helps
prevent loss of the foreign body during removal by being
sheared off at the end of the scope.
7. After foreign body removal, careful and systematic
inspection of all visible segmental and subsegmental
bronchi is necessary to ensure that the foreign body or
bodies have all been removed.
8. If during extraction the foreign body is lost and
airway obstruction occurs, it may be easiest to push the
foreign body into a distal bronchus to permit ventilation
of the patient before again attempting retrieval.

574
Section 7
Trachea and Mediastinum
A
B
C
Figure 67-18. Multipronged grasping forceps and basket devices
can be used for removal of a foreign body with a fl exible broncho-
scope. A, The instruments are passed inside a sheath through the
bronchoscope channel. B, When extended from the insertion sheath,
they can engage the foreign body. C, Tooth engaged by the basket
retrieval instrument.
Figure 67-19. Many foreign bodies, once grasped, cannot be
removed through the endotracheal tube. They should be withdrawn
tightly against the end of the endotracheal tube. The tube, broncho-
scope, and foreign body are then removed as one unit.
POSTOPERATIVE MANAGEMENT
Postoperative care of a patient who has undergone tra-
cheobronchoscopy is minimal unless signifi cant in -
strumentation has been required. A standard chest
radiograph obtained in the recovery room is standard
in most centers. If there is concern for a potential pneu-
mothorax, the patient should be monitored closely for
several hours after the procedure. Delayed complica-
tions are rare because in most instances, any diffi culties,
if they are to occur, will arise in the immediate postop-
erative period.
specifi cally designed instrument such as wire basket
catheters, multiple-pronged grasping catheters, and
balloon catheters (Fig. 67-18). General anesthesia
should be used for removal of an object with fl exible
bronchoscopy. This avoids chasing a moving object as
the patient coughs and breathes spontaneously. The
bronchoscope is passed through an appropriately sized
endotracheal tube. Once the object has been secured,
it is withdrawn against the end of the endotracheal
tube, and both the bronchoscope and the endotracheal
tube are withdrawn together (Fig. 67-19). Rigid bron-
choscopic instruments should be immediately available
should
fl exible
bronchoscopic
extraction
be
unsuccessful.
PEARLS
Flexible Bronchoscopy
• Flexible bronchoscopy is preferred in most instances
because general anesthesia is typically not needed.
Sedation is required, as well as appropriate
monitoring.
• Flexible bronchoscopy can be performed through an
appropriately sized endotracheal tube in an
anesthetized patient.
• Right-left and anterior-posterior orientation during
fl exible bronchoscopy is enhanced if the surgeon
stands above the head of the patient.
• Reorientation can often be enhanced by removal of
the camera head (if possible).
• Some foreign bodies can be removed with fl exible
instrumentation; however, such removal should be
performed in the operating suite under general
anesthesia.
• Familiarity with bronchoscopic anatomy and
instrumentation is a prerequisite.

Chapter 67
Bronchoscopy and Tracheoscopy
575
References
1. Stock CR: Esophagoscopy. Ear Nose Throat J 64:502-503, 1985.
2. Grant AK: A century of upper gastrointestinal tract endoscopy.
Med J Aust 2:903-906, 1973.
3. Berci G: History of endoscopy. In Berci G (ed): Endoscopy. New
York, Appleton-Century-Crofts, 1976, pp xix-xxiii.
4. Zollner F: Gustave Killian, father of bronchoscopy: Historical
vignette. Arch Otolaryngol 82:656-659, 1965.
5. Jackson C, Jackson CL: Technique of bronchoscopy and laryngos-
copy. In Jackson C, Jackson CL (eds): Bronchoesophagology.
Philadelphia, WB Saunders, 1950, pp 40-67.
6. Ikeda S, Yanai N, Ishikawa S: Flexible bronchofi berscope. Keio J
Med 17:1-16, 1968.
Rigid Bronchoscopy
• Rigid bronchoscopy should be performed only by
those with skill and experience.
• Children, in particular, should be referred to a
specialized center for rigid bronchoscopy and
removal of foreign bodies.
• A selection of appropriately sized bronchoscopes,
telescopes, and instruments must be available
before initiating the procedure.
• Communication between the surgeon and
anesthesiologist is required for safe performance of
bronchoscopy.
• Diffi culty ventilating the patient should immediately
result in reappraisal of the equipment and airfl ow
system. If ventilatory problems persist, the patient
should be intubated with a cuffed endotracheal tube
and then examined for the possibility of a
pneumothorax.
• Procedures performed in the airway of children are
inherently more risky and more diffi cult.
Consequently, endoscopic procedures on the airway
of children should be performed only by persons
who are trained in their performance and have
access to the appropriate equipment.
• Manipulation of obstructing lesions of the trachea
and bronchi can result in perforation of the airway
or unmanageable bleeding requiring thoracotomy.
PITFALLS
• There is a signifi cant “learning curve” for
bronchoscopy.
• Communication with the anesthesiologist is
necessary to prevent disaster in procedures
performed under general anesthesia.
• Close monitoring is essential during and after all
bronchoscopic procedures.

Chapter 68
Tracheostomy
Karen M. Kost and Eugene N. Myers
Tracheostomy was fi rst described many centuries ago.
Alexander the Great is reported to have “punctured the
trachea of a soldier with the point of his sword when he
saw a man choking from a bone lodged in his throat”
in the fourth century bc.1,2 The fi rst successful trache-
ostomy was attributed to Antonio Musa Brasavola, who
recorded saving the life of a patient close to death from
an “abscess of the windpipe” in 1546. In 1620, Nicholas
Habicot of Paris published a 108-page book on trache-
ostomy, the fi rst work devoted solely to this operation.
One of the patients he described was a 14-year-old boy
who intentionally swallowed a bag of gold coins to
prevent their theft. The bag lodged in his esophagus
and produced upper airway obstruction. Habicot per-
formed a tracheostomy to improve the airway and then
manipulated the bolus, initiating its esophageal descent.
Despite these success stories, tracheostomy remained a
marginal procedure viewed with suspicion and fear for
several centuries because of very high morbidity and
mortality rates. In 1799, when Dr. Elisha Dick recom-
mended tracheostomy for a patient in airway distress,
two colleagues vocally opposed him, and on December
14, 1799, George Washington died of acute upper
airway obstruction.
Prevailing attitudes toward tracheostomy changed
dramatically in the 19th century. The description in
1825 of a lifesaving tracheostomy in a child seems to
have singularly had the greatest impact. In that year,
Bretonneau saved the life of a 5-year-old girl named
Elisabeth de Puysergur who was suffering from diphthe-
ria by performing a tracheostomy. In 1833, Armand
Trousseau related, “I have now performed the opera-
tion in more than 200 cases and I have the satisfaction
of knowing that one-fourth of these operations were
successful.”
Cautiously, the indications for tracheostomy
expanded and the procedure became more widely
accepted. During this time, subjects such as technique,
complications, tube morphology, tracheostomy place-
ment, and anesthesia were hotly debated in the medical
literature, and there were almost as many views as there
were surgeons. Many of the patients who underwent
tracheostomy suffered from diphtheria and unfortu-
nately died of the toxic effect of the disease, even
though the airway obstruction had been relieved by the
procedure. It was to be the work of Chevalier Jackson
in 1909 that would earn tracheostomy a solid and per-
manent place in the surgeon’s armamentarium. Jackson
standardized the technique and indications for the
operation, and demonstrated that with attention to a
few key technical points, the morbidity and mortality
from the procedure could be dramatically reduced.3,4
Jackson emphasized the importance of a long incision,
avoidance of the cricoid cartilage, routine division of
the thyroid isthmus, slow and careful surgery, use of a
proper cannula, and meticulous postoperative care.
Jackson’s teachings were in large part responsible for
reducing the mortality of tracheostomy to less than 2%
and reducing the incidence of laryngeal stenosis, par-
ticularly in children.
Over the years, the indications for tracheostomy
have continued to change in parallel with the evolution
of medicine. Endotracheal intubation for short-term
airway protection and/or ventilation has replaced tra-
cheostomy in treating several conditions. Currently, the
majority of tracheostomies are performed in critically
ill patients. Other indications include sleep apnea,
chronic lung disease, primary alveolar hypoventilation
syndrome (Ondine’s curse), and conditions requiring
home mechanical ventilation.5,6
577

578
Section 7
Trachea and Mediastinum
PATIENT SELECTION
The primary objective of a tracheostomy is to secure an
artifi cial airway. Current major indications for tracheos-
tomy include: (1) relief of upper airway obstruction
(both acute and chronic), (2) providing a means for
assisted mechanical ventilation, and (3) enabling more
effi cient tracheobronchial toilet. The decision to carry
out a tracheostomy is complex, and numerous factors
must be considered to ensure that this is the optimal
procedure for the individual patient. These factors
include the relative advantages and risks of tracheos-
tomy versus alternative methods of providing an artifi -
cial airway, the facilities of the institution, the skills of
the personnel, the unique features of the patient’s
airway and respiratory physiology, and the specifi c dis-
order or disease process and its likely course.7
Patients with upper airway obstruction should be
managed initially by endotracheal intubation, when
possible, to stabilize the airway and the patient’s general
condition. Treatment of the condition may permit extu-
bation, rendering tracheostomy unnecessary. Examples
include management of acute epiglottitis in children or
adults, and angioneurotic edema of the larynx.
Patients with upper airway obstruction, from laryn-
gotracheal trauma or neoplasms of the upper aerodi-
gestive tract, may be stabilized with endotracheal
intubation initially but are likely to require conversion
to a tracheostomy. Laryngeal papillomatosis and sub-
glottic hemangioma are examples of neoplastic proc-
esses in children that may require a tracheostomy (Fig.
68-1).
Patients with chronic upper airway obstruction
will require a tracheostomy in the management of
their problem. Such conditions affect patients with
nasal and craniofacial anomalies, such as Crouzon’s
disease, large nasal encephalocele, Treacher-Collins
syndrome, subglottic stenosis, and laryngeal and sub-
glottic webs. Some patients develop iatrogenic laryngeal
or subglottic stenosis from chronic airway management,
such as those in the neonatal intensive care unit with
respiratory
insuffi ciency
who
require
artifi cial
ventilation.
Patients who require ventilatory assistance, such as
those with central nervous system disorders, stroke,
drug ingestion, or respiratory failure, should soon
undergo conversion from endotracheal intubation to
tracheostomy. The fact that prolonged endotracheal
intubation of the larynx causes laryngeal stenosis and
other laryngeal complications has made tracheostomy
useful in such settings.
Patients with chronic obstructive pulmonary disease,
adult respiratory distress syndrome, and crush injuries
to the chest, who require effi cient pulmonary toilet,
may also be well managed by tracheostomy.
PREOPERATIVE PLANNING
Every effort should be made to ensure that the patient’s
condition is optimized before surgery. Coagulopathies
should be corrected to an International Normalized
Ratio (INR) of less than 1.5, with more than 50,000
functioning platelets. Cessation of aspirin or other
nonsteroidal anti-infl ammatory medications for 10 days
preoperatively is ideal but not absolutely necessary. A
cross-match should be obtained if the hemoglobin is
less than 10 g.
Patients presenting with stridor require a safe airway
fi rst and foremost. In some cases, this may be achieved
with endotracheal intubation with or without endo-
scopic guidance. Situations involving severe facial or
laryngeal trauma may make intubation an unsuitable,
even dangerous, choice. In these instances, emergency
bedside tracheostomy may be a lifesaving measure. An
unstable airway is one of the few true emergencies that
may lead to death, and its management requires mobi-
lization of the team to stabilize the airway as quickly as
possible.
Traditionally, tracheostomy has been performed in
the operating room (OR), which is fully equipped with
adequate lighting, suction, and assistance. Admitted
patients as well as those from the emergency depart-
ment, are best transferred to the controlled, monitored
setting of the OR whenever possible. Intubated adult
patients from the intensive care unit (ICU) may undergo
tracheostomy safely either at the bedside8-10 or in the
OR11,12 with comparable complication rates.
If possible, the anesthesia team should be present
during tracheostomy, because patients who have a
chronic form of respiratory insuffi ciency with high CO2
levels may lose their respiratory drive following estab-
lishment of their airway. Such patients require close
monitoring of all vital signs, and in severe cases may
also require assisted ventilation and even cardiopulmo-
nary resuscitation.
Figure 68-1. Large volume papilloma obstructing the airway in a
young child.

Chapter 68
Tracheostomy
579
SURGICAL TECHNIQUE
The patient is placed on the operating table with a
rolled towel or sheet under the shoulders to extend the
neck unless the patient has documented or suspected
cervical spine injuries. In such cases, extension of the
neck is contraindicated because of the risk of spinal
cord compression. Adults with airway obstruction may
not be able to tolerate the supine position, and trache-
ostomy may need to be performed with the patient
sitting up at 45 degrees. Patients with severe cervical
osteoarthritis, kyphoscoliosis, or other conditions, in
whom the neck cannot be hyperextended, present a
formidable surgical challenge. The use of local or
general anesthesia may be dictated by the circum-
stances. Patients with a marginal airway and respiratory
distress must be managed with local anesthesia alone
without sedation to prevent suppressing the respiratory
drive. In more elective situations, with a protected
airway, either general anesthesia or local anesthesia
with intravenous sedation may be appropriate. In chil-
dren, the procedure is typically carried out under
general anesthesia.
Lidocaine (Xylocaine) 1% with 1:100,000 epineph-
rine is injected into the skin and subcutaneous tissue
where the incision will be placed. This maneuver may
be helpful regardless of anesthetic technique because
of the benefi ts of local vasoconstriction. The neck, face,
upper chest, and shoulders are prepared with a povi-
done-iodine (Betadine) or other suitable solution, and
a drape is placed to allow easy access to the neck and
oral cavity.
A transverse incision is made approximately 1 cm
above the suprasternal notch or 2 cm below the cricoid
cartilage. Sharp dissection is carried through the sub-
cutaneous tissue. Four small rake retractors are used
to provide good exposure. The anterior jugular veins
should be identifi ed and retracted laterally (Fig. 68-2).
It is not necessary to ligate these vessels unless they are
inadvertently cut. The strap muscles are split in the
midline and retracted laterally (Fig. 68-3A). The thyroid
isthmus is visualized and the anterior wall of the trachea
identifi ed (see Fig. 68-3B). In adults, the thyroid isthmus
can often be retracted superiorly and the trachea
entered (see Fig. 68-3C). If the trachea cannot be
exposed otherwise, the isthmus is undermined and
grasped with right-angled clamps, transected, and then
ligated with 2-0 silk or Vicryl suture on a cutting needle.
In patients under local anesthesia, it is important to
inject additional lidocaine in the paratracheal tissues
before opening the trachea to obtain effective anesthe-
sia. Once the trachea is identifi ed, a tracheal hook is
placed in the area of the second tracheal ring and held
by an assistant to immobilize the trachea in the wound.
In infants and children, a vertical incision is made
between the second and the third or the third and the
fourth tracheal rings without removing any cartilage.
Traction sutures are then placed just lateral to the inci-
sion (Fig. 68-4).
In adults, the anterior portion of the third or fourth
tracheal ring removal may facilitate insertion of the
tracheostomy tube. In most older patients, the tracheal
ring is calcifi ed, and heavy scissors must be used to
excise a small portion of the tracheal ring after trans-
verse incisions have been made in the area just above
and below the tracheal ring. This maneuver effectively
leaves a rectangular window in the trachea (Fig. 68-5).
If necessary, the opening may be enlarged by removing
additional cartilage with a Kerrison rongeur. Removal
of the anterior aspect of the tracheal ring ensures that
the cannula is placed in the trachea rather than in a
false passage anterior to the trachea.13
Traction sutures are inserted to reduce the possibil-
ity of creating a false passage in the event that the tra-
cheostomy tube becomes displaced in the immediate
postoperative period before a tract has been formed.
These are placed in the trachea with a ligature carrier
loaded with 2-0 silk (Fig. 68-6). A ligature carrier is
easier to manipulate in the depths of the wound than
a curved needle. While the tracheal hook retracts the
trachea inferiorly, the ligature carrier is passed through
the interspace just above the ring superior to the stoma
and into the lumen, with care taken not to penetrate
the posterior tracheal wall. A small, curved clamp is
used to grasp the suture and to stabilize it while the
ligature carrier is removed. A similar procedure is
carried out inferiorly. Alternatively, traction sutures
may also be placed in the lateral tracheal wall. Traction
is applied to both sutures to exteriorize the stoma and
retract the wound edges. The tracheostomy tube is
placed in the tracheal lumen, and the traction sutures
are then tied and fi xed to the skin of the chest with
adhesive tape.
Once the traction sutures have been satisfactorily
placed, the tracheal cannula may be introduced into
Figure 68-2. Retractors promote good visualization of the opera-
tive fi eld.

A
C
B
Figure 68-3. A, The strap muscles are split in the midline and retracted laterally.
B, The trachea and thyroid isthmus are identifi ed. C, The trachea is entered through
an incision between the second and the third tracheal rings as the thyroid isthmus
is retracted superiorly, or divided, as required.
Figure 68-4. Traction sutures are placed lateral to the stoma in
children. No cartilage is removed.
Figure 68-5. A portion of the tracheal ring is removed to form a
window in the trachea.
580

Chapter 68
Tracheostomy
581
the stoma. This is begun with the cannula at right angles
to the trachea; then, as the cannula is inserted, it is
turned so that its axis is parallel to that of the trachea
(Fig. 68-7A). This eliminates the diffi culty encountered
in trying to pass the cannula over the patient’s chest.
An obturator should always be used while the cannula
is inserted. Once the cannula is properly placed in
the trachea, the obturator is removed promptly and
the inner cannula inserted. Once the tracheostomy
tube is in place and adequate ventilation through the
tracheostomy tube is assured, the endotracheal tube or
bronchoscope used to stabilize the airway may be
removed.
The tracheostomy cannula is secured by suturing
the neck plate to the skin and by tracheostomy tapes
tied securely with a square knot with the neck fl exed.
Only one fi ngertip should be admitted between the
tape and the patient’s neck, and the tapes should be
tied over the skin and not over a bulky dressing. When
tapes are tied over bulky dressings, the stability of the
tracheostomy tube is compromised. This is a major
cause of tube displacement in the early postoperative
period. In patients undergoing head and neck surgery,
the tape is not used if it crosses the cervical fl ap incision
or causes constriction of the blood supply of a regional
fl ap brought up through the neck. In such cases, the
tube is sutured to the underlying skin with 2-0 silk
sutures (see Fig. 68-7B).
When a tracheostomy is carried out under ideal
circumstances, with enough time for vasoconstriction,
bleeding is minimal. It is important to secure all bleed-
ing points, with either ligatures or electrocautery, to
prevent bleeding postoperatively. Caution should be
exercised when using electrocautery close to the trachea
because of the risk of airway fi re. To reduce the possibil-
ity of this catastrophic event, the patient should be
ventilated on the lowest possible oxygen concentration,
and the trachea should never be entered with
electrocautery.
To prevent subcutaneous emphysema, the incision
should not be sutured or packed. The wound may be
left open or a very light dressing applied.
When the cannula is removed, the wound heals by
secondary intention, forming a transverse scar, which is
generally less unsightly than the scar left by a vertical
incision. When subcutaneous and deeper tissues are
properly undermined and retracted, the same amount
of working space is obtained through a transverse inci-
sion as through a vertical incision.
Figure 68-6. Traction sutures are placed superior and inferior to
the stoma in adults.
A
B
Figure 68-7. A, The tracheostomy tube is inserted into the trachea.
B, The neck plate of the tracheostomy tube is sutured to the skin.
The use of tapes is optional.

582
Section 7
Trachea and Mediastinum
POSTOPERATIVE CARE
The choice of the proper tracheostomy tube is impor-
tant. The purpose of a tracheostomy tube is (1) to
provide an airway, (2) to provide for the possibility of
artifi cial positive pressure ventilation if needed, (3) to
seal the trachea to reduce aspiration of material from
above the tube or in the hypopharynx, and (4) to
provide a means of suctioning the tracheobronchial
tree.14 Aspects of tube selection include the shape of
the tube and the neck plate. If a cuffed tube is neces-
sary, it should be a low-pressure, high-volume cuff to
reduce the possibility of tracheal stenosis. Tubes with
an inner cannula provide an added safety dimension in
that the inner cannula can be quickly removed in case
there is a mucous plug, leaving the outer cannula in
situ and the airway protected.
Preoperative planning should also account for any
special type of tracheostomy tube reguirements. For
instance, obese patients with thick pretracheal soft
tissues may require extended-length tubes to decrease
the risk of accidental decannulation or tube displace-
ment. Tracheostomy tubes with either proximal or
distal extensions are available. Tubes with adjustable
fl anges and those made of softer, thermolabile materi-
als for anatomically diffi cult situations are also available.
Some patients may benefi t from a Passey-Muir valve in
the postoperative period. These valves allow the genera-
tion of subglottic pressure and therefore facilitate
deglutition. The surgeon must therefore be certain that
the correct tracheostomy tube is chosen to accommo-
date these situations.
Postoperative care of the tracheostomy is greatly
facilitated through preoperative teaching. This helps
allow both children and adults undergoing tracheos-
tomy to adjust to this new way of breathing. Evidence
indicates that patients undergoing tracheostomy expe-
rience a reduced quality of life.15 Family counseling is
extremely important to support the patient during this
time. Highly skilled nursing care is fundamental to the
success of this procedure.
In the initial postoperative period, patients are
placed in a semi-Fowler position to maximize the ease
of coughing and deep breathing, to facilitate suction-
ing, and to minimize discomfort. Vital signs require
frequent monitoring because changes in blood pres-
sure, respiratory rate, or pulse rate may indicate that
there is a new or ongoing respiratory problem or that
the tube may be plugged or have come out of the
trachea. Similarly, agitation, anxiety, and restlessness
may all indicate hypoxia. Tracheal suctioning is per-
formed to maintain pulmonary toilet and patency of
the tracheostomy tube. Initially, this should be done as
aseptically as possible and may be necessary three to
four times daily. Either a portable or a wall suction unit
may provide the negative pressure needed for suction-
ing. Patients on mechanical ventilation are at risk for
hypoxia and cardiac arrhythmias during suctioning
because oxygen-rich air is suctioned and catheters may
be too large. This can be prevented by applying suction
for up to 12 seconds with a small catheter and ventilat-
ing the patient on 100% O2 for at least fi ve breaths
before and after suctioning. As an alternative to this
open technique, a closed, multiple-use suction catheter
contained within a sheath may be used.16
Humidifi cation is extremely important to facilitate
mucociliary transport of secretions and to prevent crust-
ing, accumulation of secretions, and eventual obstruc-
tion of the airway. Humidifi cation is usually delivered
through a tracheal mask. The use of a T-tube is avoided
because the torque exerted on the tracheostomy tube
traumatizes the tissue every time the patient moves.
Meticulous local wound care is of paramount
importance. The tracheostomy site should be cleaned
as often as necessary with normal saline or hydrogen
peroxide to prevent breakdown of the skin and the
progression from wound colonization to infection. Ini-
tially, this should be three or four times daily. The twill
tapes that hold the tracheostomy tube in place should
be changed as necessary. The skin under the tracheos-
tomy neck plate should be kept dry with a thin nonad-
herent dressing such as Telfa to prevent maceration. It
takes at least 48 to 72 hours for a tract to form around
the tracheostomy tube. Accordingly, the surgeon should
avoid changing the tube until adhesions form between
the overlying soft tissues and the trachea. Accidental
decannulation in the early postoperative period is more
dangerous because the tissues collapse, sealing off the
airway. Changing the tracheostomy tube requires some
fi nesse, and early on it is not necessary unless the patient
is to be changed from a cuffed to an uncuffed tube or
if the cuff fails. Tube replacement in the fi rst 48 hours
requires:
• Optimal patient positioning
• Assistance
• Adequate light
• Tracheal hook
• Suction
In addition, the use of a tracheostomy tube
exchanger may be extremely useful. The exchanger is
a long semifl exible tube with a central lumen through
which ventilation is possible. The exchanger is inserted
into the tracheostomy tube, which is then removed and
replaced with the new tube. The exchanger “guides”
the new tracheostomy tube into the trachea. If for any
reason the new tracheostomy is diffi cult to replace,
ventilation may be temporarily continued through the
exchanger.
The inner cannula must be removed frequently
and cleaned to make sure that mucus obstruction does
not occur. Decannulation in adults can be safely accom-
plished by following a few simple steps. Indirect or fl ex-
ible endoscopy should be used to ensure that the upper
airway is adequate and the larynx is competent. The
tube may then be downsized and plugged during waking
hours. The patient must be instructed to remove the
plug in the event of dyspnea or shortness of breath. If
the patient tolerates the plug for 24 hours, the cannula
can be removed and the stoma covered with a light
dressing and occlusive tape. The period of plugging
allows for adequate evaluation of airway adequacy. It

Chapter 68
Tracheostomy
583
also affords time for laryngeal adductor refl exes to be
activated. If the plug is not tolerated further, the nature
of the obstruction must be investigated.
Children should undergo endoscopy before decan-
nulation. Often a granuloma in the stomal site is found;
removing the granulomas enhances successful decan-
nulation. If the airway is adequate, the patient can be
decannulated.
COMPLICATIONS
Complications of tracheostomy may be divided into
intraoperative, immediate postoperative, and late post-
operative complications. Most complications of trache-
ostomy can be prevented or minimized by providing
optimal conditions, which include adequate light,
suction, and assistance. For admitted patients or airway
emergencies, the surgery is best done in the controlled
setting of the OR. For those patients in respiratory dis-
tress, the airway should be secured whenever possible
by insertion of an endotracheal tube before proceeding
to the OR. For adult intubated ICU patients, the pro-
cedure may also be safely performed at the bedside, as
long as adequate light, suction, and assistance are
available.
Intraoperative Complications
Hemorrhage
Hemorrhage may be related to the patient ingesting
anticoagulants, aspirin, or nonsteroidal anti-infl amma-
tory agents. These may contribute to excessive bleeding
during the procedure and in the immediate postopera-
tive period. Patients with coagulation disorders, such as
hemophilia, leukemia, or liver disease, may also have
excessive bleeding. Every effort should be made to
correct these problems preoperatively unless the situa-
tion is emergent, in which case correction may be
undertaken during the procedure. The surgeon must
be absolutely meticulous in controlling the bleeding.
Bleeding during tracheostomy may be minimized
by careful attention to the details of the procedure.
When using local anesthesia, the procedure should
not be begun until adequate vasoconstriction has
been achieved. Bleeding is usually minimized by staying
in the midline with the dissection, being cautious
to dissect layer by layer, and maintaining adequate
light and assistance with retraction of the soft tissues.
Bleeding from transection of the anterior jugular
vein, the thyroid isthmus, and a high innominate artery
are all possible and should be dealt with appropriately
by identifying, ligating, or cauterizing the offending
vessel. Injury to the innominate artery may require
repair and the expertise of a vascular surgeon. Intro-
duction of the tracheal cannula may cause a paroxysm
of coughing, and bleeding may occur at that time.
Appropriate retraction, suction, and lighting will facili-
tate identifi cation and ligation of the involved vessel.
Packing should be avoided because extravasation of air
through the packing during coughing predisposes to
subcutaneous emphysema.
Intraoperative Tracheoesophageal Fistula
Intraoperative tracheoesophageal fi stula has been
reported when the tracheal wall has been injured inad-
vertently, usually during an “urgent” tracheostomy with
over penetration of the trachea itself. If this is recog-
nized at the time, it may be necessary to open the neck
once the airway has been established and indivi dually
close the wounds in the trachea and the esophagus.
Pneumothorax
Pneumothorax is most likely to occur in a patient suf-
fering from air hunger. It may also be due to direct
puncturing of the pleura by the surgeon. This latter
situation is most common in children, in whom the
apex of the lung protrudes into the lower neck and is
more vulnerable to injury. Pneumothorax may also
occur when the tracheostomy tube is inserted between
the anterior wall of the trachea and the soft tissues of
the anterior mediastinum, creating a “false passage”
(Fig. 68-8). This condition is much less likely to occur
if the cannula is inserted with adequate exposure,
retraction, and the use of traction sutures.
Pneumomediastinum
Pneumomediastinum is most common in children and
is usually noted on routine chest radiographs. This
Figure 68-8. Mechanism of false passage between the sternum (S)
and the trachea (T). (From Myers EN, Stool SE, Johnson JT: Complications
in tracheostomy. In Myers EN, Stool SE, Johnson JT [eds]: Tracheostomy. New
York, Churchill Livingstone, 1985, p 150.)

584
Section 7
Trachea and Mediastinum
complication may be due to excessive dissection of the
paratracheal soft tissues or when the patient is strug-
gling to breathe against an obstructed airway. Excessive
coughing that forces air from the open tracheostomy
into the deeper planes of the neck may also result in
pneumomediastinum. Patients with pneumomediasti-
num are generally asymptomatic, and no therapy is
required.
Cardiopulmonary arrest may occur in patients who
have had chronic air hunger and elevated CO2 levels.
The anesthesia team should be alerted to this possibility
in the event that cardiopulmonary resuscitation is nec-
essary. Sudden relief of chronic upper airway obstruc-
tion may also result in congestive heart failure due to
extravasation of fl uid into alveoli in response to reduc-
tion of obstruction-induced positive end-expiratory
pressure.
Fire
Fire during tracheostomy is rare and may be a cata-
strophic event. External burns may result from the use
of electrocautery shortly after prepping the skin with
alcohol-containing solutions. This is of particular
concern in hirsute patients, in whom body hair inter-
feres with the drying of the solution. Therefore, every
effort should be made to ensure that the operative fi eld
is completely dry before electrocautery use, or the solu-
tions should be avoided when possible.
Fire may also occur when using electrocautery in
the presence of high concentrations of oxygen, whether
delivered by mask (as in local procedures) or via the
endotracheal tube under general anesthesia. Oxygen
concentrations should be kept at a minimum safe con-
centration for the patient, and cautery should never be
used to enter the airway. In the unfortunate instance of
an airway fi re, the immediate response includes turning
off the oxygen, changing the endotracheal tube, and
the use of water in the fi eld, followed by bronchoscopy
to assess the extent of injury, medical treatment with
antibiotics and steroids, and observation in the ICU.
The best treatment consists of instituting all measures
necessary to prevent such events.
Immediate Postoperative Complications
Tube Obstruction
Tube obstruction may be caused by thick mucus or
blood clots. This complication is potentially fatal. These
may be prevented by attentive nursing care, proper
humidifi cation, and frequent suctioning. The use of a
tracheostomy tube with an inner cannula that allows
regular inspection, cleansing, and suctioning is critical.
If for some reason the obstructed tube cannot be
cleared, it should be removed and replaced.
Displaced Tracheostomy Tube
Displacement of the tracheostomy tube may occur at
any time and is potentially fatal. This complication is
most dangerous in the immediate postoperative period
before a tract has formed in the soft tissues around the
tracheostomy tube. Patient factors that may predispose
to displacement of the tube include obesity, excessive
coughing, and agitation. Physical factors include incor-
rect placement of the opening into the trachea, creat-
ing a false passage (see Fig. 68-8), loosening of the tapes
as a result of resolution of subcutaneous emphysema,
inadequately tied tracheostomy tapes, and use of bulky
dressings. Such situations are largely preventable by
suturing the neck plate to the skin surrounding the
tracheostoma.
Displacement of the tracheostomy tube should be
suspected when a patient with a fresh tracheostomy
develops respiratory distress or is suddenly able to
speak. Management of this displacement may be facili-
tated by traction sutures. When the complication is rec-
ognized, the traction sutures should be pulled gently
and then returned to a position parallel with the
patient’s neck. This will retract the skin and bring the
stoma into the wound. The tracheostomy tube is then
inserted and adequate ventilation verifi ed. If this pro-
cedure fails or in a patient with known diffi cult anatomy,
it may be best to reintubate the patient and fi nd the
tracheostomy tract once the airway is secured. Identify-
ing the stoma with suction tubing and inserting the
tracheostomy tube into the trachea is an alternative
method of restoring the airway.
Postoperative Hemorrhage
Postoperative bleeding may occur when the vasocon-
striction from the epinephrine wears off or if vessels
that were injured during surgery were not ligated.
Treatment requires identifi cation and ligation of vessels.
For “oozing,” use of a hemostatic packing such as Sur-
gicel may be helpful. Coagulopathies should be identi-
fi ed and corrected. If there is signifi cant bleeding, the
patient should be returned to the OR, the wound
explored, and hemostasis achieved. Packing an actively
bleeding tracheostomy site is contraindicated because
of the potential for subcutaneous emphysema.
Wound Infection
The tracheal wound is colonized within 24 to 48 hours
by many species of organisms, including Pseudomonas
and Escherichia coli, as well as gram-positive cocci.13 It is
not possible to prevent colonization. Tracheostomy
tubes are also colonized by bacteria such as Staphylococ-
cus epidermidis, which are imbedded in biofi lm. The
longer the tube is in place, the heavier the load of
biofi lm. This biofi lm functions as a “coat of armor” of
sorts, effectively protecting bacteria from local and/or
systemic antibiotics. A true infection of the tracheal
stoma is uncommon. Antibiotics may simply select for
colonization by a resistant organism. Regular tracheos-
tomy tube changes every 2 weeks for admitted patients
may decrease the incidence of granulation tissue and
biofi lm formation.16,17
The fundamental principle is meticulous hygiene
with suctioning, cleansing, dressing and tie changes,
and tube changes when necessary to remove crusts and
necrotic debris, thereby reducing bacterial load. Trac-
tion sutures should be removed after the fi rst tube
change. True infection with surrounding cellulitis is

Chapter 68
Tracheostomy
585
unusual and should be treated with organism-specifi c
antibiotics and aggressive local wound care with
débridement.
Tracheobronchitis may be due to underlying disease
or aspiration, or both. Treatment is with suctioning,
vigorous pulmonary exercise (blow bottles, cupping
and clapping, ambulation), and judicious administra-
tion of antibiotics.
Rarely, necrotizing stomal infections may occur,
with substantial loss of soft tissue down to and including
the tracheal wall. Further progression of the process
may result in carotid artery exposure, with its attendant
risks. Management includes aggressive wound débride-
ment and cleaning with antiseptic dressings as well as
culture-guided antibiotics. Rarely, local fl aps may be
necessary to provide soft tissue coverage to vital
structures.16
Subcutaneous Emphysema
Air may be forced into the subcutaneous tissues during
or shortly after tracheostomy. Factors predisposing to
this complication include excessive coughing, use of
an uncuffed tracheostomy tube, tight suturing of the
wound or tracheostomy tube, and packing of the wound.
Emphysema is usually mild and may be diagnosed by
palpating crepitus in the tissues of the neck, chest, or
face. Subcutaneous emphysema is generally prevented
by using a cuffed tracheostomy tube and not packing
the wound. If the condition is severe, the wound should
be opened and any packing removed. Otherwise, no
treatment is necessary because the air is slowly absorbed
from the tissues.
Late Postoperative Complications
Granulation tissue is considered to be a late complica-
tion or sequela of tracheostomy, variably reported as
occurring in 3% to 80% of cases.17 It is also commonly
seen in children, especially those in whom a fenestrated
tube has been used. The clinical importance of granula-
tion tissue lies in its ability to bleed, complicate trache-
ostomy tube changes, delay attempts at decannulation,
and completely obstruct the tracheostomy tube with
potentially catastrophic results. Factors believed to favor
formation of granulation tissue include bacterial infec-
tion, gastroesophageal refl ux, suture material, and
powder from surgical gloves. Although a number of
topical treatments such as steroid creams, antibiotic
ointments, and silver nitrate have been suggested, larger
amounts of granulation tissue, particularly when
obstructive, may require surgical excision, with or
without the use of the laser.
The prolonged presence of the same indwelling
tracheostomy tube, which is a foreign body, elicits an
infl ammatory tissue response favoring the growth of
granulation tissue, increased secretions, and bacterial
colonization with biofi lm production.16 Regular tube
changes, on a schedule of every 2 to 3 weeks, have been
shown to dramatically reduce the incidence of this
problem.17
Late tracheoesophageal fi stula is rare and may
result from an overinfl ated or improperly fi tted cuff or
malpositioned tracheostomy cannula pushed to the
posterior wall of the trachea against an indwelling
nasogastric tube. Also, if the posterior wall of the trachea
was unknowingly penetrated during surgery, infection
may cause a tracheoesophageal fi stula. In this case, the
neck must be opened, the esophagus and the posterior
wall of the trachea must be closed individually, and soft
tissue, such as muscle, must be interposed in the defect.
More commonly, however, the passage of food through
the tracheostomy is a manifestation of aspiration rather
than of a tracheoesophageal fi stula. This can be con-
fi rmed on modifi ed barium swallow.
Rupture of the innominate artery usually occurs
within the fi rst 3 weeks after tracheostomy and may be
fatal. This complication may occur in patients of any
age and may be due to one of the following: (1) placing
the tracheostomy low in the neck, below the third tra-
cheal ring where the inferior concave surface of the
cannula may erode the artery (Fig. 68-9A), (2) an aber-
rant course of the innominate artery such that it crosses
the trachea at an abnormally high level, (3) use of an
excessively long or curved tube, the tip of which may
erode the trachea and the vessel wall deep to it (see Fig.
68-9B), (4) over hyperextending the neck during the
tracheostomy procedure, (5) prolonged pressure on
the tracheal wall by an infl ated cuff, and (6) tracheal
infection.13
Rupture of the innominate artery is usually her-
alded by a “sentinel bleed,” which may stop and be fol-
lowed a few days later by a catastrophic hemorrhage.
The patient coughs up bright red blood from the tra-
cheostomy tube. If this sign is recognized, the cuff of
the tracheostomy tube should immediately be overin-
fl ated and suprasternal pressure applied in an attempt
to control the hemorrhage. These maneuvers generally
control the bleeding at least temporarily. Transfusion
is likely to be required, and blood should be sent for
typing and cross-matching immediately. Thoracotomy
and ligation of the innominate artery may be necessary
as a lifesaving maneuver.
Tracheal stenosis and tracheomalacia are late com-
plications. Steps toward decreasing the occurrence of
these sequelae include: (1) proper placement of the
tracheostomy tube between the fi rst and third tracheal
rings, (2) use of the smallest possible tube size, (3)
minimizing cuff infl ation pressures, and (4) minimizing
cuff infl ation times.
Tracheocutaneous fi stula, depressed scar, and
laryngotracheal stenosis are discussed in Chapters 45
and 51.
PERCUTANEOUS DILATATIONAL
TRACHEOSTOMY IN THE
INTENSIVE CARE UNIT
Critically ill patients represent a particular subset of the
population by virtue of their multisystem disease state
and the complexity of the care they require. Tracheos-
tomy is a frequently performed procedure in this patient
population and is associated with a higher risk.16 As

586
Section 7
Trachea and Mediastinum
such, special consideration is required in terms of indi-
cations, technique, and care. Moving these critically ill
patients with their monitors requires additional person-
nel and carries a number of different risks, including
accidental extubation and vital sign changes requiring
pharmacologic intervention.16 Endoscopic percutane-
ous dilatational tracheostomy is especially well suited to
patients in the ICU because it is safe, simple, and can
be performed at the bedside thereby, reducing the
need and associated costs of using the OR.
Standard surgical tracheostomy (ST) at the bedside
in the ICU is often inconvenient and requires transport-
ing instrument trays, adequate suction, extra lighting,
and electrocautery from the OR. The procedure may
be further compromised by the lack of trained OR
nurses and assistants. Risks include inadequate or diffi -
cult visualization, and spontaneous ignition with the use
of electrocautery in the presence of greater than or
equal to 30% O2.
Seldinger’s description in 1953 of catheter replace-
ment of the needle in percutaneous anteriography over
a guidewire served as a basis for the development
of several percutaneous tracheostomy techniques.
Although many of these early procedures were quickly
abandoned, interest in this area persisted, and in 1985,
when Ciaglia described bedside percutaneous dilata-
tional tracheostomy,18 the procedure was rapidly
adopted in many ICUs, principally by critical care physi-
cians and anesthesiologists. The technique is based on
progressive dilatation of an initial tracheal puncture.
There were early concerns about safety because the
procedure, as originally described, was blind. With the
notable addition of endoscopic guidance, fi rst reported
in 61 patients by Marelli and colleagues,19 the “blind”
aspect has been addressed. The author’s experience
with more than 500 cases has demonstrated that, with
bronchoscopic visualization and attention to technical
detail, endoscopic percutaneous dilatational tracheos-
tomy (PDT) is a safe, cost-effective alternative to surgi-
cal tracheostomy in the OR, with complication rates
comparable with or lower than those of ST.20
PATIENT SELECTION
It must be stressed that PDT is suitable only in adult
intubated patients in monitored settings. This patient
population accounts for almost two thirds of all trache-
ostomies performed today.
Anatomic and medical suitability for this procedure
must be determined preoperatively with the patient’s
neck extended.20,21 Contraindications to PDT include
the inability to palpate the cricoid cartilage above the
sternal notch, the presence of a midline neck mass, a
high innominate artery, or large thyroid gland. Patients
with these conditions should undergo ST in the OR.
Coagulopathies are common in this patient population
and should be corrected as much as the patient’s condi-
tion allows preoperatively. Ideally, platelets should
be 50,000 or greater and the INR corrected to less
than or equal to 1.5. Patients requiring a positive end-
expiratory pressure (PEEP) of greater than or equal to
15 cm H2O are at high risk for complications such as
subcutaneous emphysema and pneumothorax and
should undergo ST in the OR. Patients having had a
previous tracheostomy may undergo PDT as long as
they have no contraindications.20
Nonintubated patients with acute airway compro-
mise constitute an absolute contraindication to PCT.
A
B
Figure 68-9. A, Mechanism of
erosion of the innominate artery
(IA) by pressure from the concave
surface
of
the
tracheostomy
cannula. B, Pressure of the tip of
the tracheostomy cannula on the
anterior tracheal wall (T) causes
erosion into the innominate artery
(IA). (From Myers EN, Stool SE,
Johnson JT: Complications in tracheos-
tomy. In Myers EN, Stool SE, Johnson
JT [eds]: Tracheostomy. New York,
Churchill Livingstone, 1985, p 167.)

Chapter 68
Tracheostomy
587
The procedure requires a secure airway for broncho-
scopic visualization through an endotracheal (ET) tube
or laryngeal mask airway. The different airway anatomy
and dimensions in the pediatric population as well as
the technical diffi culties of maintaining adequate ven-
tilation with a bronchoscope within a small ET tube
render the procedure completely unsuitable in this age
group.21
PREOPERATIVE PLANNING
Preoperative testing is minimal and includes a recent
chest radiograph as well as serum determination of
hemoglobin, prothrombin time, partial thromboplastin
time, and platelets. Cross-matching is not necessary
even in the presence of low hemoglobin levels. A fully
equipped intubation cart should be available nearby in
the event of accidental extubation during the proce-
dure. Special consideration should be given to obese
patients or those with a short, thick neck. Thick subcu-
taneous tissues in this group place them at particular
risk for accidental decannulation. This potential
problem may be circumvented by using an extended
length (proximal) tracheostomy tube.20
Personnel
In addition to the attending staff surgeon, a resident or
critical care colleague is required to perform the bron-
choscopy, and a respiratory technician is needed to
assist in suctioning, adjusting ventilator settings, and
hold the ET tube fi rmly in position. A nurse is needed
to administer medication, monitor vital signs, and
help obtain necessary materials and instruments. The
surgeon and necessary instruments are positioned to
the patient’s right, the respiratory technician to the left,
and the bronchoscopist at the head of the bed.
Instruments
Currently, the simplest and most thoroughly evaluated
kit is the Ciaglia Blue Rhino Percutaneous Introducer
Kit (Cook Critical Care Inc., Bloomington, IN). This
kit relies on dilatation of an initial tracheal puncture
using a single, sharply tapered dilator with a hydro-
philic coating. The tracheostomy tube is fi tted with a
loading dilator before insertion. A 26F loading dilator
is required to insert a no. 6 Shiley tracheostomy tube,
and a 28F loading dilator is used to insert a no. 8 Shiley
tracheostomy tube. Shiley Per-Fit tracheostomy tubes
are commercially available and have been specially
designed and tapered to permit easier insertion. The
size of the tube can be determined at the time of the
procedure.
Other required instruments include a scalpel,
curved hemostat, straight scissors, a needle driver, non-
resorbable sutures, water-based lubricant, three 10-mL
syringes, and an appropriately sized tracheostomy tube.
The instruments should be placed on an instrument
stand over the patient’s bed and in the order in which
they are to be used. An appropriately sized broncho-
scope with a suction port must be chosen to fi t within
the ET tube while still allowing adequate ventilation. A
pediatric bronchoscope may be required for ET tubes
less than 8 mm internal diameter. Almost any broncho-
scope may be used in patients ventilated through a
laryngeal mask airway. If available, a video monitor may
be connected to the bronchoscope, allowing full visual-
ization of the intratracheal portion of the procedure by
the operating surgeon and staff.
Anesthesia
Any procedure involving manipulation of the trachea is
highly stimulating to the patient and requires adequate
local anesthesia supplemented by intravenous sedation.
Local anesthesia, consisting of 1% or 2% lidocaine with
1:100,000 epinephrine is used for generous infi ltration
of the incision site and pretracheal soft tissue. Topical
anesthesia in the form of 2% to 4% lidocaine may be
injected through the bronchoscope and is useful in
decreasing the cough refl ex. Intravenous sedation is
also required with the particular drug combination
dependent on the individual patient and the institu-
tion. Frequently used medications include propofol,
administered as a continuous infusion or in boluses,
midazolam, and fentanyl (Sublimaze). Muscle relaxants
such as pancuronium bromide may be used as an
adjunct when agitation is a problem. The presence of
an anesthetist is optional and may depend on hospital
policy. Care should be exercised in administering these
medications particularly in the older patient because
large fl uctuations in blood pressure and heart rate may
occur even with small doses.20
TECHNIQUE
Following appropriate sedation, ventilator settings are
adjusted to deliver 100% O2 and allow for the presence
of the bronchoscope. Vital signs, including heart rate,
blood pressure, and oxygen saturation, are monitored
continuously throughout the procedure. The instru-
ments for the Ciaglia Blue Rhino Introducer Set are
illustrated in Figure 68-10. Instruments are laid out on
a Mayo stand in the anticipated order of use (Fig.
68-11). The patient is positioned as for conventional
tracheostomy with the neck extended as long as there
is no contraindication (e.g., cervical spine fracture).
Important anatomic landmarks including the thyroid
and cricoid cartilages and the sternal notch are pal-
pated. The patient’s neck and upper chest are then
prepped and draped in a standard fashion and the inci-
sion site is infi ltrated with 2% lidocaine with 1:100,000
epinephrine.
A 1.5- to 2-cm. skin incision, just long enough to
insert a tracheostomy tube, is made at the level of the
fi rst and second tracheal rings. This corresponds to
approximately one fi ngerbreadth above the sternal
notch or two fi ngerbreadths below the cricoid. The
subcutaneous tissues are gently separated horizontally
with a curved hemostat to allow accurate palpation of
the cricoid cartilage and tracheal rings. No attempt is
made to divide or otherwise manipulate the isthmus of
the thyroid gland.

588
Section 7
Trachea and Mediastinum
At this point the patient is suctioned and 1 to 2 mL
of 4% lidocaine may be instilled into the ET tube to
decrease coughing. Any tapes or ties must be loosened
to allow manipulation of the ET tube. An appropriately
sized fl exible bronchoscope with a suction port is
inserted through an adapter into the ET tube and
advanced until the tip of the bronchoscope lies fl ush
with the ET tube. During this step, the bronchoscope
light will be seen through the incision as it is advanced
into the ET tube. From this point on, the ET tube must
be held securely by the bronchoscopist or respiratory
technician to prevent accidental extubation. The ET
tube (with the cuff momentarily defl ated) and bron-
choscope are slowly withdrawn as a unit until the inci-
sion is transilluminated and/or digital depression of
the trachea is endoscopically visualized. All ensuing
steps are visualized through the bronchoscope. With
the ET tube and bronchoscope properly positioned,
the tracheal rings are palpated and a no. 14 or no. 16
Tefl on catheter introducer needle is inserted between
the fi rst and second or second and third tracheal rings
(Fig. 68-12). The location of the needle is verifi ed endo-
scopically and modifi ed until a midline intercartilagi-
nous position is achieved. Care is taken not to puncture
the posterior tracheal wall. The needle is removed, and
a J-tipped guidewire is threaded through the remaining
catheter into the trachea (Fig. 68-13). This catheter
sheath is removed and replaced by a 14F introducer
dilator (Fig. 68-14). Removal of this introducer dilator
facilitates the passage and positioning of the 12F guiding
catheter over the guidewire between the markings. The
guiding catheter and J-wire then form a unit (Fig.
68-15), over which further dilatation is achieved
using a single, sharply tapered soft-tipped dilator with
Curved J-wire
J-wire guide
Introducer dilator
Guiding catheter
Loading dilators
Blue Rhino Dilator
Catheter introducer needle
Safety
ridge
Figure 68-10. Ciaglia Blue Rhino
Percutaneous Introducer Set by
Cook. Instruments in the single
dilator kit.
Figure 68-11. Cook kit: instru-
ments arranged in order of use,
left to right: (1) Syringe with local
anesthesia, (2) scalpel, (3) curved
hemostat, (4) syringe with no. 16-
gauge introducer needle, (5) J-
wire, (6) 14F introducer dilator,
(7) guiding catheter, (8) single
dilator, (9) tracheostomy tube
with loading dilator, inner cannula,
and water-based lubricating jelly
for the tracheostomy tube. Top:
Saline to activate the hydrophilic
coating, gauze, silk suture, straight
scissors, toothed forceps, needle
driver.

Chapter 68
Tracheostomy
589
Figure 68-12. With the bronchoscope positioned in the
endotracheal tube, the 16-gauge introducer needle is inserted
between the fi rst and second or second and third tracheal
rings. Note position of endotracheal tube with the cuff just
below the vocal folds. The bronchoscope projects a short dis-
tance beyond the tip of the endotracheal tube.
Figure 68-13. The 16-gauge introducer needle is
removed, leaving only the sheath, through which the
J-tipped guidewire is introduced.
Figure 68-14. The introducer needle Tefl on sheath is
removed and replaced by the 14F introducer dilator. This
facilitates the next step, placement of the 12F guiding
catheter.

590
Section 7
Trachea and Mediastinum
a hydrophilic coating activated by dipping it in saline.
This single dilator is held like a pen, and introduced
over the guidewire/guiding catheter unit in an arc con-
forming to the tract undergoing dilatation. Some col-
lapse of the anterior tracheal wall may occur during
dilatation (Fig. 68-16). Slight overdilatation facilitates
placement of the tracheostomy tube. The tracheostomy
tube, prefi tted with the appropriately sized loading
dilator, is threaded over the guidewire/guiding cathe-
ter unit into the trachea (Fig. 68-17). Two points of
resistance are typically encountered during this maneu-
ver: the interface between the loading dilator and tra-
cheostomy tube, and on insertion of the balloon.
At this point, the dilator, guiding catheter, and
J-wire are removed (Fig. 68-18) and replaced with the
inner cannula. The cuff is infl ated and ventilation is
continued through the tracheostomy tube. The trache-
ostomy tube is secured with four corner sutures and
tape ties. Blood and/or secretions are suctioned from
the trachea. Only when adequate ventilation is estab-
lished can the ET tube be removed. The vocal cords
may be inspected on removal of the bronchoscope and
ET tube.
Tracheostomy tube size is chosen based on the
clinical needs and gender of the patient with a prefer-
ence for smaller no. 6 internal diameter (I.D.) tubes in
females whenever possible. In a patient with a short,
thick neck, a longer tracheostomy tube should be used
to prevent accidental displacement of the tube into the
pretracheal soft tissue.
Depending on the degree of calcifi cation of the
tracheal cartilages, fracture of the ring immediately
adjacent to the dilator may occur during dilatation.
This is akin to intentionally incising one (or more)
ring(s) during an open surgical tracheostomy. This is
clinically insignifi cant and does not increase the inci-
dence of tracheomalacia or tracheal stenosis.20
POSTOPERATIVE CONSIDERATIONS
Particular care is taken in monitoring for changes in
vital signs such as hypotension, tachycardia, or O2 desat-
Figure 68-15. The 14F introducer dilator is removed,
and replaced by the 12F guiding catheter, which is posi-
tioned over the guidewire between the markings. Note the
direction of the arrow and the small ridge (placed close to
the skin) on the guiding catheter. The J-wire and guiding
catheter form a unit over which subsequent dilatation is
achieved.
Figure 68-16. The sharply tapered single dilator is dipped
in water to activate its hydrophilic coating. It is held like a pen
and introduced over the J-wire/guiding catheter unit into the
trachea. Slight overdilatation is desirable to facilitate place-
ment of the tracheostomy tube.

Chapter 68
Tracheostomy
591
uration. With the termination of the intense stimula-
tion produced by the procedure, the effects of the
sedation may become more pronounced, resulting in
hypotension and requiring pharmacologic correction.
Suctioning may be required to clear secretions or blood,
thus preventing a drop in O2 saturation. A postopera-
tive chest radiograph is required to ensure the absence
of pneumothorax and pneumomediastinum.
Many of these patients have copious secretions from
the tracheostomy site from their associated pulmonary
condition. A tracheostomy tube with an inner cannula
facilitates care and hygiene, and ensures added safety by
allowing rapid removal in case obstruction from secre-
tions occurs. The PDT technique is primarily dilata-
tional with minimal tissue dissection, resulting in a
tighter tract and a very snug fi t of the tracheostomy tube.
The technique does not allow placement of traction
sutures at the level of the trachea. Because of these
factors, the patient should be reintubated orally if acci-
dental decannulation occurs within the fi rst 7 days of
the procedure while the tract is still relatively immature.
Although not specifi cally reported, attempts at replac-
Figure 68-17. The tracheostomy tube, prefi tted with the
appropriate loading dilator, is advanced over the J-wire/
guiding catheter unit into the trachea.
Figure 68-18. The loading dilator, J-wire, and guiding cath-
eter are removed and replaced by the inner cannula.
ing the tracheostomy tube in an emergent situation
could result in bleeding, the creation of a false passage,
pneumomediastinum, hypoxia, and even death.
COMPLICATIONS
Potential intraoperative and postoperative complica-
tions are similar to those reported for surgical trache-
ostomy. Notable differences in terms of frequency are
discussed below. The overall complication rate for
endoscopic PDT in the literature is approximately 9%.20
This compares favorably with that of ICU patients
undergoing open surgical tracheostomy in the OR,
where complication rates of 14% to 66% have
been reported,5,11,12,20 or at the bedside where complica-
tion rates of 4% to 41% have been reported.8-10,20
The use of continuous endoscopic visualization is
crucial to the safety of the procedure and in reducing
complications.20,21
Obese patients with a body mass index (BMI) equal
to or greater than 30 are at higher risk for complica-
tions. This risk is further increased in obese patients

592
Section 7
Trachea and Mediastinum
who are “more ill” as assessed by the American Society
of Anesthesia (ASA) classifi cation. The most common
complication in this group is accidental decannulation
due to the thickness of the subcutaneous tissues. Use of
a proximally extended cannula largely circumvents this
problem. No data are available on the risk of complica-
tions in obese patients undergoing open surgical tra-
cheostomy; similarly, there is no evidence that the risk
of complications is reduced in obese patients undergo-
ing ST.20 There is a learning curve for endoscopic PDT,
which may be reduced with appropriate training and
careful selection of patients with anatomically favorable
necks for the fi rst 30 to 40 patients. Comparative data
on individual complications (e.g., bleeding, infection)
for surgical and percutaneous tracheostomies indicate
that PDT compares favorably with ST. Notably, the inci-
dence of bleeding and infection are signifi cantly
reduced in PDT compared with ST.20
Desaturation
The real risk of desaturation is unknown because it is
infrequently reported in the tracheostomy literature.
Brief episodes of mild oxygen desaturation may occur
at the time of tracheostomy tube insertion, particularly
in patients with compromised pulmonary function
requiring high FIO2 concentrations.20 The risk of such
an occurrence may be minimized by ventilating all
patients on 100% oxygen for the duration of the pro-
cedure and ensuring thorough preoperative and intra-
operative suctioning of secretions.
Bleeding
There is a lower incidence of bleeding complications in
PDT compared with ST. This can be explained by the
blunt nature of the technique as well as the tamponade
effect of the tracheostomy tube against the tight tract
that is created.20,21
Infection
PDT is associated with a lower risk of infection com-
pared with ST. Because of the small wound and tight
tract in PDT, the surface area available for bacterial
colonization is markedly reduced compared with that
following the sharp soft tissue dissection in ST.20,21
Accidental Extubation
The true incidence of accidental extubation for either
PDT or open surgical tracheostomy is diffi cult to esti-
mate because it is infrequently mentioned in the litera-
ture. The risk of this complication may be reduced
through the following steps: the endotracheal tube
should be held and manipulated principally by a physi-
cian with the assistance (when needed) of a respiratory
therapist, and such manipulation should only occur
after the bronchoscope has been inserted.
Posterior Wall Injury
Occasional overzealous initial needle insertion may
puncture the posterior tracheal wall, but this is clini-
cally insignifi cant and is easily corrected by simply with-
drawing the needle to the appropriate position. Serious
posterior wall injury can be avoided by attention to
technical detail (proper positioning of the guidewire,
guiding catheter, and dilator) and, most importantly,
constant endoscopic visualization of the posterior wall
during the procedure.20
Technical Misadventures
Loss of the puncture site and accidental removal of the
J-wire include some of the possible technical mishaps.
In these instances, the procedure must be continued
from the previous step or started anew as dictated by
the circumstances. Occasionally, dilatation may be dif-
fi cult because resistance is encountered. In this case,
the size of the incision and soft tissue “tunnel” should
be verifi ed. As a rule, the surgeon’s index fi nger should
fi t comfortably in the incision and soft tissue tunnel. If
not, additional spreading of the soft tissue should
correct the problem. If the initial needle insertion is
through a tracheal ring, dilatation will be diffi cult and
the needle should be repositioned between rings. If the
tracheostomy tube is diffi cult to insert, the tract should
be “redilated.” The use of excessive force during any
step of the procedure always indicates a problem and
should never be used because it is likely to lead to com-
plications and/or damage the instruments. Technical
problems may prolong the procedure but rarely directly
impact patient safety or outcome.20
False Passage, Pneumothorax,
and Pneumomediastinum
These potentially fatal complications can be almost
completely avoided by continuous bronchoscopic visu-
alization of every step of the procedure.20 Excessive
force should never be used during dilatation or trache-
ostomy tube insertion, and always indicates a technical
problem.
Accidental Decannulation
Accidental decannulation is unusual because of the
tight tract. Most at risk are obese patients or those with
a short, thick neck in whom subcutaneous adipose
tissue effectively shortens the intratracheal length
of the tracheostomy tube. This potential problem may
be circumvented by using proximally extended length
tracheostomy tubes.20
OTHER CONSIDERATIONS
PDT is signifi cantly faster to perform compared with
surgical tracheostomy.20-22 From a training perspective,
most residents consider endoscopic PDT to be easier
than surgical tracheostomy. There is a clear cost advan-
tage to PDT when compared with open surgical trache-
ostomy in the OR.20-22 The cost of PDT may be slightly
higher when compared with open bedside tracheos-
tomy because of the cost of the kit.20 The simple instru-
mentation, convenience, and scheduling fl exibility of
bedside PDT constitute signifi cant advantages that
offset minor cost differences.

Chapter 68
Tracheostomy
593
SUMMARY
Over the course of centuries, tracheostomy has evolved
into a safe procedure fi rmly entrenched in the sur-
geon’s armamentarium. Attention to technical detail is
essential in minimizing the risk of complications.
Endoscopic percutaneous dilatational tracheos-
tomy is a safe and attractive bedside alternative to open
surgical tracheostomy in intubated adult ICU patients.
Obese individuals are at an increased risk for accidental
decannulation regardless of the technique used.
Extended length tracheostomy tubes should be used in
these patients. The use of bronchoscopy is mandatory
with PDT and markedly reduces or eliminates the risk
of life-threatening complications such as pneumotho-
rax, pneumomediastinum, false passage, and even
death. Endoscopic PDT is at least as safe as surgical
tracheostomy. Furthermore, it is rapid, simple, conve-
nient, and completely independent of OR schedules.
Consistently high standards of nursing care are key
in preventing complications regardless of the surgical
technique used. Timely changes of soiled tracheostomy
ties, frequent cleaning of the surgical site, and attention
to the neck plate–skin interface all minimize the likeli-
hood of skin maceration, breakdown, and wound infec-
tion. Continuous high humidity, judicious suctioning
using proper technique, and frequent cleaning and/or
changing of the inner cannula effectively prevent the
formation of mucous plugs.
References
1. Gordon BL: The Romance of Medicine. Philadelphia, FA Davis,
1947, p 461.
2. Frost EAM: Tracing the tracheostomy. Ann Otol 85:618, 1976.
3. Jackson C, Jackson CL: The Larynx and Its Diseases. Philadelphia,
WB Saunders, 1937.
4. Jackson C: High tracheostomy and other errors. The chief causes
of chronic laryngeal stenosis. Surg Gynecol Obstet 32:392, 1923.
5. Zeitouni A, Kost K: Tracheostomy: A retrospective review of 281
patients. J Otolaryngol 23:61-66, 1994.
6. Eavey RD: The evolution of tracheostomy. In Myers EN, Stool SE,
Johnson JT (eds): Tracheostomy. New York, Churchill Living-
stone, 1985, pp 1-11.
7. Davis HW, Johnson JT: Decision making in airway management
of children and adults. In Myers EN, Stool SE, Johnson JT (eds):
Tracheostomy. New York, Churchill Livingstone, 1985, pp
13-39.
8. Futran ND, Dutcher PO, Roberts JK: The safety and effi cacy of
bedside tracheostomy. Otolaryngol Head Neck Surg 109:707-711,
1993.
9. Wease GL, Frikker M, Villalba M, Glover J: Bedside tracheostomy
in the intensive care unit. Arch Surg 131:552-555, 1996.
10. Upadhyay A, Maurer J, Turner J, et al: Elective bedside tracheos-
tomy in the intensive care unit. J Am Coll Surg 183:51-55, 1996.
11. Stauffer JN, Olson DE, Petty TL: Complications and consequences
of endotracheal intubation and tracheostomy: Prospective study
of 150 critically ill adult patients. Am J Med 70:65-76, 1981.
12. Dayal VS, Masri WE: Tracheostomy in the intensive care setting.
Laryngoscope 96:58-60, 1986.
13. Myers EN, Stool SE, Johnson JT: Technique of tracheostomy. In
Myers EN, Stool SE, Johnson JT (eds): Tracheostomy. New York,
Churchill Livingstone, 1985, pp 113-124.
14. Lindholm CE: Choice of tracheostomy. In Myers EN, Stool SE,
Johnson JT (eds): Tracheostomy. New York, Churchill Living-
stone, 1985, pp 125-146.
15. Gilony D, Gilboa D, BlumsteinT, et al: Effects of tracheostomy on
well-being and body image perceptions. Otolaryngol Head Neck
Surg 133:366-371, 2005.
PEARLS
• The airway should be stabilized by endotracheal
intubation or introduction of a bronchoscope to
ensure an orderly tracheostomy.
• Patients who will require long-term ventilatory
assistance should undergo earlier conversion from
endotracheal intubation to tracheostomy to prevent
complications such as laryngeal or subglottic
stenosis.
• Traction sutures in open surgical tracheostomy are
helpful in maintaining an airway in cases of a
displaced tracheostomy tube in the immediate
postoperative period.
• Extended length tracheostomy tubes should be used
in obese patients to reduce the risk of accidental
decannulation.
• Preoperative and/or predischarge teaching makes
postoperative care of the tracheostomy considerably
easier for the patient.
• The use of bronchoscopy is mandatory in all cases
of percutaneous dilatational tracheostomy.
• Endoscopic percutaneous dilatational tracheostomy
is especially well suited to adult patients in the
intensive care unit because it is safe, simple, and
can be performed at the bedside, reducing the need
and expense of moving the patient to the operating
room.
PITFALLS
• Failure to stabilize the airway before tracheostomy
may result in intraoperative or postoperative
complications or death.
• Delay in conversion from long-term endotracheal
intubation to tracheostomy may result in laryngeal
or subglottic stenosis.
• Absence of tracheal traction sutures following open
surgical tracheostomy may compromise the ability
to appropriately reposition a displaced
tracheostomy tube in the early postoperative period.
• Lack of adequate light, suction, retraction of tissues,
as well as failure to maintain dissection in the
midline may lead to injury to major arteries and
nerves.
• Unless the anesthesia team is present and alerted,
adequate cardiopulmonary resuscitation may not be
available for the patient undergoing tracheostomy
for chronic obstruction of the airway.
• Inadequate training, inappropriate patient selection,
and lack of attention to technical detail may
increase the risk of complications in endoscopic
percutaneous dilatational tracheostomy.

594
Section 7
Trachea and Mediastinum
16. Kost KM: Tracheostomy in the intensive care unit setting. In
Myers EN, Johnson JT, Murray T (eds): Tracheostomy: Airway
Management, Communication, and Swallowing. San Diego: Sin-
gular Publishing, 1998, pp 75-96.
17. Yaremchuk K: Regular tracheostomy tube changes to pre -
vent formation of granulation tissue. Laryngoscope 113:1-10,
2003.
18. Ciaglia P, Firsching R, Syniec C: Elective percutaneous dilata-
tional tracheostomy. A new simple bedside procedure; prelimi-
nary report. Chest 87:715-719, 1985.
19. Marelli D, Paul A, Manolidis S, et al: Endoscopic guided per-
cutaneous tracheostomy: Early results of a consecutive trial. J
Trauma 30:433-435, 1990.
20. Kost K: Percutaneous tracheostomy. Laryngoscope 115(suppl):1-
30, 2005.
21. Kost KM: The optimal technique of percutaneous tracheostomy.
Int J Intens Care 8:82-88, 2001.
22. Barba CA, Angood PB, Kauder DR, et al: Bronchoscopic guid-
ance makes percutaneous tracheostomy a safe cost-effective, and
easy-to-teach procedure. Surgery 118:879-883, 1995.

Chapter 69
Laryngotracheal Separation
Eugene N. Myers
The three major functions of the larynx include airway
protection, airway maintenance, and phonation. When
airway protection is compromised to the extent
of intractable aspiration, patients can no longer
nourish themselves by oral alimentation and are also
subject to recurrent and potentially fatal aspiration
pneumonia.
Chronic aspiration can result from any condition
that affects the ability of the larynx to perform one of
its primary functions, that of airway protection.1 Patients
at risk for chronic aspiration and aspiration pneumo -
nia include those with (1) chronic debilitating central
nervous system disease, including stroke; (2) esopha-
geal dysfunction2; (3) myopathies2; and (4) advanced
cancer of the larynx and oropharynx in patients who
require combined therapy.1
Takamizawa and coauthors3 reported a series of 11
children ranging in age from 3 months to 16 years who
had intractable aspiration pneumonia. These patients
all had chronic, severe neurologic disorders. None of
the patients had verbal communication. Yamana and
coworkers4 reported a series of nine patients with intrac-
table aspiration pneumonia. The patients ranged in age
from 4 to 71 years. A tracheostomy was previously placed
in six patients; however, the use of a cuffed tracheos-
tomy tube did not prevent aspiration. Three of these
patients also had severe gastroesophageal refl ux
disorder.
Broniatowski and associates5 pointed out that an
estimated 500,000 patients per year in the United States
are affected by stroke-related dysphagia. Approximately
half of these patients experience aspiration that can
lead to pneumonia and death. Aspiration may result
from many factors, including late transport of the bolus,
faulty laryngeal elevation, and poor coordination or
inappropriate timing of vocal cord closure.
Most patients with intractable aspiration will have
already had a tracheostomy. Many of the patients will
respond to conservative measures such as dietary modi-
fi cation, postural changes, compensatory maneuvers,
and the use of prosthetic devices.1
When conservative measures fail to control the aspi-
ration or when the aspiration pneumonia becomes
intractable, adjunctive surgical procedures may be used,
including6
• Tracheostomy
• Cricopharyngeal myotomy
• Gastrostomy
• Jejunostomy
• Injection of the vocal cords
• Thyroplasty for vocal cord medialization
Unfortunately, these adjunctive procedures will not
usually be suffi cient to prevent intractable aspiration
pneumonia.
Multiple laryngeal closure procedures have been
described with varying degrees of success6:
• Laryngeal stenting
• Supraglottic closure
• Glottic closure
• Tracheoesophageal diversion—Lindeman’s
procedure
• Laryngotracheal separation
• Laryngectomy
The laryngeal diversion technique (LDT) was fi rst
described by Lindeman in 1975 (Fig. 69-1).7 Modifi ca-
tions of this technique led to development of the laryn-
gotracheal separation (LTS) technique.8,9
Snyderman and Johnson10 described the character-
istics that they believed to be ideal for the surgical treat-
ment of chronic aspiration:
595

596
Section 7
Trachea and Mediastinum
• Simplicity
• Low morbidity
• Effectiveness
• Reliability
• Preservation of vocal and swallowing function
• Reversibility
LTS meets all these criteria except for preservation
of vocal function. LTS is usually favored over LDT
because of ease of performance. The condition of
patients with intractable aspiration pneumonia is usu -
ally poor. LTS requires less time to perform because
tracheoesophageal diversion is not necessary. It is also
possible to perform LTS under local anesthesia, which
is a signifi cant advantage for patients with impaired
respiratory function.4
Eibling and associates11 endorsed the success of
LTS. More recently, Takamizawa and coauthors3 carried
out LTS in a series of 11 children with severe neurologic
disorders. LTS decreased the frequency of performing
suction from an average of once every 30 minutes to
once every 4.5 hours in all patients. Pneumonia was
eliminated completely in 10 of 11 patients. The remain-
ing patient only had one episode of pneumonia post-
operatively. Two of the patients who were not able to
eat before LTS could eat table food postoperatively.
Yamana and colleagues4 reported a series of 9 patients
with intractable aspiration pneumonia who underwent
LTS. None of the patients had aspiration pneumonia
postoperatively.
I recently performed LTS successfully in an elderly
woman
with
complete
oropharyngeal
stenosis
as a result of attempting suicide by the ingestion of a
caustic substance. The patient had chronic aspiration
pneumonia before LTS, but no aspiration or pneumo-
nia occurred after LTS.
Broniatowski and coworkers5 reported their experi-
ence with “dynamic laryngotracheal closure” for aspira-
tion. They studied two stroke patients with chronic
aspiration diagnosed on modifi ed barium swallow. They
used a device (Huntington Medical Research Institute
Bipolar Helical Electrodes) linked to a NeuroControl
Implantable Receiver-Stimulator on the left recurrent
laryngeal nerve. The device was successfully triggered
intraoperatively and postoperatively, which demon-
strated that aspiration is systematically arrested with low
levels of electrical stimulation. This pioneering work
has shown that aspiration can be controlled without
airway damage in a wide population of neurologically
impaired patients because it is more physiologic than
surgical treatment.
Unfortunately, both LTS and LDT disconnect the
vocal cords from their pulmonary power source.1 There-
fore, patients and their surgeons often have to make
the diffi cult decision of oral nutrition versus the pulmo-
nary power source. Usually, the decision is based on the
life-threatening reality of death from intractable aspira-
tion pneumonia.
Darrow and colleagues12 performed tracheoesopha-
geal puncture after LTS in a select group of patients.
Apparently, they had success in this group of patients,
who then continued to not aspirate and were able to
phonate. Lombard and Carrau1 in 2001 described a
tracheotracheal puncture. This technique followed LTS
and had the advantage of protection against aspiration
and yet allowed laryngeal communication.
PATIENT SELECTION
Recurrent aspiration pneumonia, which can be fatal,
may develop in patients with central nervous system
disorders or structural abnormalities of the oral cavity
or oropharynx. Management of these patients with
intractable aspiration is diffi cult, partly because of the
wide variety of manifestations, underlying illnesses, and
levels of residual pharyngeal function (Table 69-1). A
wide assortment of useful therapeutic modalities, both
surgical and nonsurgical, are feasible (Tables 69-2 and
69-3). When conservative treatment of chronic aspira-
tion fails, surgery is indicated. The surgery must be
designed to eliminate communication between the
pharynx and larynx.
Patients who are candidates for LTS have either
acute or chronic aspiration that does not permit oral
alimentation and may also produce life-threatening
aspiration pneumonia. The decision to perform LTS is
complex because of the anxiety produced by contem-
plating the loss of voice. After successful LTS patients
may regain their ability to swallow without aspiration.
Some of the developments listed earlier, such as dynamic
laryngotracheal closure and tracheotracheal puncture,
Figure 69-1. Lindeman’s procedure. The proximal trachea is
diverted into the esophagus. (From Eibling DE, Bacon GW, Snyderman
CH: Surgical management of chronic aspiration. Adv Otolaryngol Head Neck
Surg 6:107, 1992.)

Chapter 69
Laryngotracheal Separation
597
may be able to allow patients not only to swallow without
aspiration but also to phonate. However, patients should
be counseled that such treatment is impossible in some
cases, particularly in patients who are relatively alert or
who may have had an acute exacerbation of laryngeal
dysfunction and aspiration and may be expected to
recover, such as a patient whom we treated some years
ago who had an exacerbation of her multiple sclerosis
with severe aspiration. The patient was treated by LTS
when tracheostomy failed to control the aspiration. She
went into remission and was able to have the LTS taken
down and a tracheal anastomosis carried out. A useful
algorithm is presented in Figure 69-2.
PREOPERATIVE PLANNING
Ideally, LTS should be performed before a tracheos-
tomy. Unfortunately, this is not usually feasible because
the underlying aspiration or associated neuromuscular
process has already led to the performance of a trache-
ostomy. Moreover, the severity of aspiration and its role
in the disease process are often not suspected until after
Table 69-1
PATHOLOGIC STATES ASSOCIATED
WITH ASPIRATION
Surgical
Skull base
Head and neck
Thyroid carcinoma
Supraglottic laryngectomy
Major oropharyngeal resection
Carotid endarterectomy
Anterior spinal fusion
Reduced Consciousness
Alcohol or sedative drug overdose
Head injury
General anesthesia
Gastrointestinal Disease
Zenker’s diverticulum
Esophageal neoplasm
Neurologic and Neuromuscular Disease
Cerebrovascular accident
Intracranial tumors
Amyotrophic lateral sclerosis
Parkinson’s disease
Myasthenia gravis
Polymyositis/dermatomyositis
Guillain-Barré syndrome
Dystonia/tardive dyskinesia
Vocal cord paralysis
Progressive muscular dystrophy
Meningitis
Table 69-2
NONSURGICAL TREATMENT OF
ASPIRATION
Nothing by mouth
Nasoenteric feeding or gastrostomy
Swallowing therapy
Postural feeding technique
Table 69-3
SURGICAL TREATMENT OF
ASPIRATION
Adjunctive Procedures
Tracheostomy
Cricopharyngeal myotomy
Gastrostomy/feeding jejunostomy
Thyroplasty for vocal cord medialization
Defi nitive Procedures
Laryngeal stenting
Supraglottic closure
Glottic closure
Tracheoesophageal diversion—Lindeman’s procedure
Laryngotracheal separation
Laryngectomy
Abnormal function with
intact glottic sensation
No laryngeal function or
no glottic sensation
Laryngotracheal separation
Massive Aspiration
Chronic
Acute
Nasogastric tube
Gastrostomy tube
Tracheostomy
adjunctive
procedure (see Table 69–3)
Extubation
Passy-Muir valve
Failure
Figure 69-2. Algorithm for the evalua-
tion and management of the aspirating
patient. (From Snyderman CH, Johnson JT,
Eibling DE: Laryngotracheal diversion and sepa-
ration in the treatment of massive aspiration.
Curr Opin Otolaryngol Head Neck Surg 2:66,
1994.)

598
Section 7
Trachea and Mediastinum
tracheostomy, when copious tracheal secretions become
obvious. LTS after tracheostomy is technically more dif-
fi cult and results in the creation of a shorter proximal
stump. This will make reconstruction, if clinically indi-
cated later, technically more diffi cult.
Antibiotics
are
administered
perioperatively,
although patients are usually ill and normally in an
intensive care unit. Generally, they have been given
multiple antibiotics and are frequently colonized by
multiple organisms. As a result, the effi cacy of periop-
erative antibiotics is open to question. During family
counseling it is important to not make too many prom-
ises regarding the ability of the patient to swallow after
the procedure. Less than half the patients in the Uni-
versity of Pittsburgh series11 were able to subsist without
enteral feeding after LTS. Moreover, the family and
patient must understand that there is nearly a one in
three risk of a fi stula developing from the proximal
stump.13
PROCEDURE
The patient is positioned and draped as for a tracheos-
tomy. If a tracheostomy has previously been performed,
the incision is widened laterally, and the previous tra-
cheostomy scar and granulation tissue are excised from
the skin down to the level of the trachea. Patients who
have not undergone tracheostomy previously are
approached as they would be for a routine tracheos-
tomy—via a horizontal incision with dissection through
subcutaneous tissue and splitting of the strap muscles
to expose the trachea. Division of the thyroid isthmus
may also be necessary to gain adequate exposure for
closure of the proximal stump of the trachea in patients
who have previously undergone tracheostomy.
The location for the separation is identifi ed at the
site of the previous tracheostomy or at the interspace
of the third or fourth tracheal ring. In older patients
with an increased anteroposterior dimension of the
chest, the larynx may be located more inferiorly and be
resistant to retraction superiorly. In these patients the
trachea may need to be divided more superiorly, at the
second interspace. The higher levels of tracheal divi-
sion may make the procedure easier; however, the short
stump dramatically increases the diffi culty of reanasto-
mosis if attempted later. In most patients who have
previously undergone tracheostomy, the proximal
trachea will usually consist of only one or two rings
above the level of the stoma.
When the trachea has been identifi ed, dissection is
carried laterally around the trachea at the site of the
stoma. If the patient does not have an indwelling tra-
cheostomy, an endotracheal tube must be passed
through the wound into the distal trachea for ventila-
tion throughout the remainder of the procedure. The
trachea is then transected, with care taken to maintain
the dissection next to the wall of the trachea to avoid
injury to the recurrent laryngeal nerves. The posterior
wall is then transected with care taken to not enter the
esophagus. This can be performed by either bluntly
dissecting posterior to the trachea or continuing the
Figure 69-3. Laryngotracheal separation. The proximal trachea is
closed as a blind pouch. (From Eibling DE, Bacon GW, Snyderman CH:
Surgical management of chronic aspiration. Adv Otolaryngol Head Neck Surg
6:108, 1992.)
incisions through the lateral walls bilaterally and across
the posterior wall until they meet. Care should be taken
to maintain this line of transection in a straight trans-
verse plane to avoid tapering superiorly such that
closure of the proximal stump becomes problematic
(Fig. 69-3).
Once the trachea has been divided, it is dissected
free in both a superior and an inferior direction. Care
should be taken to avoid extending the dissection too
far into the soft tissues laterally to prevent recurrent
laryngeal nerve injury. An incision is made in the fascia
to expose the inferior-most ring in the upper stump.
The ring is then dissected free with a small periosteal
elevator. Care should be taken to avoid injury to the
underlying mucosa. Removing this ring frees the inter-
nal mucoperichondrium and permits mucosal closure
(Fig. 69-4). So that collapse of the upper stump is fully
accomplished, the second to the last ring (usually the
fi rst or second tracheal ring) is divided anteriorly to
allow the ring to collapse on itself and reduce tension
on the mucosal closure (Fig. 69-5).
The mucosa is then closed in a running inverting
fashion similar to a pharyngeal closure (see Fig. 69-5).
The mucosal closure is reinforced by additional inter-
rupted sutures placed through the remaining, but
divided tracheal ring. This effectively reinforces the
closure and helps prevent postoperative leaks (Fig.
69-6).

Chapter 69
Laryngotracheal Separation
599
Figure 69-4. After the trachea is divided, a ring is removed by dis-
secting the cartilage away from the mucosa. This provides mucosa for
closure.
Figure 69-5. Stump closure. The
next ring above is then divided (A),
and the mucosa is closed in water-
tight fashion with inverting continu-
ous suture (B).
A
B
Some surgeons routinely reinforce the closure with
a fl ap of strap muscle sewn below the proximal tracheal
closure. Unfortunately, this maneuver does not always
prevent a fi stula. An adequate inverting mucosal closure
performed without tension appears to be the most criti-
cal step in this part of the procedure.
The distal trachea is then brought to the skin, and
a stoma is formed in a manner identical to that for a
laryngectomy stoma. Half-mattress sutures are used to
advance skin from the lateral to the medial aspect as
would occur in a total laryngectomy (Fig. 69-7). A small
Penrose drain is brought out one corner of the wound,
and any remaining skin lateral to the tracheostoma is
then closed. A cuffed tracheostomy tube is inserted to
help prevent aspiration of any wound drainage that
seeps from the skin edges.
POSTOPERATIVE CARE
The Penrose drain is generally removed the next day,
and the cuffed tracheostomy tube can often be replaced
with a laryngectomy tube in 2 to 3 days. Feeding can be
started as early as 3 to 5 days, depending on the meta-
bolic condition of the patient, the degree of aspiration
preoperatively, the patient’s ability to tolerate an oral
diet, and perceived adequate healing of the wound.
Postoperative care is similar to that for a laryngectomy,
and routine stomal care will be required.

600
Section 7
Trachea and Mediastinum
Figure 69-7. After closure. Note the Penrose drain left in place for
24 hours to avoid subcutaneous collection of fl uid.
the procedure that has been performed, particularly if
the patient is transferred to another facility.
In the series of patients treated at the University of
Pittsburgh, transient fi stulas occurred in approximately
a third of the patients undergoing separation proce-
dures.13 Postoperative fi stula has occurred more com-
monly in patients who have previously undergone
tracheostomy and is usually secondary to technical dif-
fi culties in closing the mucosa of the proximal trachea
stump.
Less than half of patients treated by LTS at the
University of Pittsburgh were able to swallow after
surgery.13 The lack of swallowing was due to the underly-
ing neurologic disease that necessitated the procedure
and was not a complication of the procedure. The
major diffi culty in the procedure is selection of patients
for it, not the procedure itself.
PEARLS
• LTS can be a lifesaving procedure in patients with
chronic aspiration.
• LTS can be reversed if the cause of the aspiration is
overcome (e.g., a patient with an exacerbation of
multiple sclerosis going into remission).
• Tracheoesophageal puncture can be performed in
some patients to restore their ability to speak.
• LTS can be performed under local anesthesia in
patients whose general condition will not allow
general anesthesia.
• Patients whose underlying condition permits may
resume swallowing a few days after LTS.
A
B
Figure 69-6. Reinforcement of the
closure. A, The ring that was divided is
then collapsed with a clamp, and an
additional layer of reinforcing sutures is
placed to reinforce the closure. B,
Operative photograph of closure of a
subglottic tracheal stump (arrow).
COMPLICATIONS
One of the factors to be considered in postoperative
management is the importance of relaying to other care
providers the procedure that was actually performed.
There is less anterior neck deformity after LTS than
after laryngectomy; hence, those unfamiliar with the
procedure might assume that this stoma represents a
routine tracheostomy with persistent communication
with the pharynx. Such assumptions can lead to inap-
propriate airway management, such as insertion of an
expiratory speaking valve or attempts to intubate the
patient through the larynx. It may be worthwhile to
have a sign placed above the patient’s bed describing

Chapter 69
Laryngotracheal Separation
601
PITFALLS
• Despite technically successful LTS, some patients will
not be able to swallow because of their underlying
neurologic condition.
• If LTS is not carried out correctly, poor healing with
fi stula formation may occur.
• Reversing LTS in patients not fully recovered from
their underlying condition will result in resumption
of chronic aspiration.
• Relying on a cuffed tracheotomy tube in a patient
with severe chronic aspiration will lead to recurrent
aspiration pneumonia.
• Patients who are highly anxious about the loss of
their voice may not be suitable candidates for LTS.
References
1. Lombard LE, Carrau RL: Tracheo-tracheal puncture for voice
rehabilitation after laryngotracheal separation. Am J Otolaryngol
22:176-178, 2001.
2. Falestiny MN, Yu VL: Aspiration pneumonia. In Carrau RL, Murry
T (eds): Comprehensive Management and Swallowing Disorders.
San Diego, CA, Singular Publishing Group, 1998, pp 383-388.
3. Takamizawa S, Tsugawa C, Nishijima E, et al: Laryngotracheal
separation for intractable aspiration pneumonia in neurologi-
cally impaired children: Experience with 11 cases. J Pediatr Surg
38:975-977, 2003.
4. Yamana T, Kitano H, Hanamitsu M, Kitajima K: Clinical outcome
of laryngotracheal separation for intractable aspiration pneumo-
nia. ORL J Otorhinolaryngol Relat Spec 63:321-324, 2001.
5. Broniatowski M, Grundfest-Broniatowski S, Tyler DJ, et al:
Dynamic laryngotracheal closure for aspiration: A preliminary
report. Laryngoscope 111:2032-2040, 2001.
6. Eibling DE: Laryngotracheal separation. In Myers EN (ed): Oper-
ative Otolaryngology–Head and Neck Surgery. Philadelphia, WB
Saunders, 1997, pp 586-591.
7. Lindeman RC: Diverting the paralyzed larynx: A reversible pro-
cedure for intractable aspiration. Laryngoscope 85:157-180,
1975.
8. Lindeman RC, Yarington CT, Sutton D: Clinical experience with
the laryngotracheal anastomosis for intractable aspiration. Ann
Otol Rhinol Laryngol 85:609-612, 1976.
9. Baron BVC, Dedo HH: Separation of the larynx and trachea for
intractable aspiration. Laryngoscope 90:1927-1930, 1980.
10. Snyderman CH, Johnson JT: Laryngotracheal separation for
intractable aspiration. Ann Otol Rhinol Laryngol 97:466-470,
1988.
11. Eibling DE, Snyderman CH, Eibling C: Laryngotracheal separa-
tion for intractable aspiration: A review of 34 patients. Laryngo-
scope 105:1-3, 1995.
12. Darrow DH, Robbins KT, Goldman SN: Tracheoesophageal
puncture for voice restoration following laryngotracheal separa-
tion. Laryngoscope 104:1163-1166, 1994.
13. Snyderman CH, Johnson JT, Eibling DE: Laryngotracheal diver-
sion and separation in the treatment of massive aspiration. Curr
Opin Otolaryngol Head Neck Surg 2:63-67, 1994.

Chapter 70
Management of Tracheal Stenosis
Ryan J. Soose and Ricardo L. Carrau
Tracheal stenosis is a rare condition that may arise from
a variety of causes, including congenital conditions, iat-
rogenic and accidental trauma, autoimmune diseases,
infections, and neoplasms. Its pathogenesis includes
injury to the tracheal lining or its cartilaginous frame-
work resulting in scarring and loss of support, with
subsequent collapse of the airway and stenosis. The
laryngotracheal cartilaginous framework depends on its
perichondrium for blood supply. Ischemic cartilage
loses its mechanical integrity and collapses, thereby
leading to a functional stenosis. Furthermore, exposed
cartilage deprived of its blood supply necroses rapidly
and acts as a foreign body; the ensuing infl amma -
tory reaction causes further tissue destruction and
scarring.
An in-depth discussion of the pathogenesis of laryn-
gotracheal stenosis is beyond the scope of this chapter.
The following includes a brief discussion of the most
signifi cant etiologic factors.
PATIENT SELECTION
External Trauma
The laryngotracheal complex is protected by the man-
dible, the sternum, and the fl exion mechanism of the
neck. However, civilian violence, motor vehicle acci-
dents, and sports injuries have led to an increase in the
frequency of post-traumatic laryngotracheal stenosis.
The incidence of laryngotracheal stenosis after external
trauma varies from 0% to 59%. Even when adequate
and immediate repair is accomplished, traumatic dis-
ruption of supporting structures, loss of mucoperi-
chondrium, or laryngotracheal separation is usually
accompanied by some degree of airway narrowing.1
Endotracheal Intubation
The incidence of laryngotracheal stenosis after pro-
longed or repeated endotracheal intubation ranges
from 3% to 8% in both adults and children.2,3 An
incidence as high as 44% has been cited for low-
birthweight neonates and those with respiratory distress
syndrome.2-4 Earlier endoscopy and tracheotomy in low-
birthweight infants and other high-risk groups may
reduce the risk of intubation-related laryngotracheal
stenosis in these patients.4
Multiple factors play a role in the etiology of laryn-
gotracheal stenosis after endotracheal intubation. Time
of intubation, size of the tube, pressure and friction by
the shaft or cuff, repeated intubation, foreign body
reaction to the tube, release of toxic substances used
for sterilization, use of a stylet, route of intubation
(nasal or orotracheal), techniques for nursing care
(suctioning, fi xation), and anatomic differences
between the genders are among many important factors
that can be correlated with the development of post-
intubation stenosis.
Nordin and Lindholm,5 using a rabbit model, cor-
related the degree of damage with time of intubation
and with characteristics of the cuff of the endotracheal
tube. They concluded that the pressure exerted by the
cuff over the tracheal tissues is more important than the
duration of intubation. Because microcirculation of
the laryngeal mucosa stops at a pressure of 30 mm Hg,
a low-volume, high-pressure cuff is more likely to cause
an ischemic injury than a high-volume, low-pressure
cuff is. Nonetheless, an overinfl ated, high-volume cuff
can stop the microcirculation and produce the same
injury as a low-volume cuff.
603

604
Section 7
Trachea and Mediastinum
Whited,6 in a dog model, demonstrated how the
biomechanics of endotracheal tubes produces ulcer-
ation of the posterior glottis and circumferential injury
of the subglottis and trachea. Whited7 confi rmed the
fi ndings of his animal study in a clinical prospective
study that correlated the degree of injury with patterns
and length of intubation. Patients who were intubated
endotracheally for 2 to 5 days had a 0% to 2% incidence
of chronic laryngotracheal stenosis, those intubated for
5 to 10 days had a 4% to 5% incidence, and those
intubated for more than 10 days had a 12% to 14%
incidence. He suggested that a tracheotomy may prevent
laryngotracheal stenosis in patients who need endotra-
cheal intubation for more than 10 days. It should be
remembered, however, that the type of tracheotomy
incision and biomechanical factors related to the tra-
cheotomy tube also contribute to the development of
stenosis.
Bryce8 also correlated the time of intubation with
laryngeal injuries. Lesions caused by repeated intuba-
tion were the most severe. His fi ndings suggested that
perichondritis is the most signifi cant factor for the
development of stenosis.
Age is another important factor infl uencing the site
and degree of stenosis. Neonates show a predisposition
for subglottic involvement,2 whereas adults are more
prone to scarring in the posterior commissure.3,6 Nev-
ertheless, combined stenoses account for about one
third of all laryngeal stenoses at any age.
Infectious, Autoimmune, and
Granulomatous Diseases
Tuberculosis, histoplasmosis, blastomycosis, leprosy,
and syphilis are endemic in several areas of the world.
They share a common phase of erythema and edema
that progresses to chondritis, necrosis, and scarring.9
Diseases
such
as
relapsing
polychondritis
and
Wegener’s granulomatosis may destroy the cartilagi-
nous framework and thereby lead to collapse of the
airway. Subglottic stenosis occurs in 10% to 20% of
patients with Wegener’s granulomatosis, and the main-
stay of treatment remains medical (e.g., cyclophospha-
mide, steroids). Surgical therapy, which usually consists
of dilatation and adjuvant modalities such as injectable
steroids and topical mitomycin C, is typically reserved
for those who have failed medical treatment and is used
only during disease remission.10,11
Gastropharyngeal Refl ux
Repeated exposure to pepsin and acid (i.e., gastric
refl uxate) produces mucosal and submucosal injuries
leading to scarring.12 Patients with laryngotracheal ste-
nosis and those at risk for the development of stenosis
should be carefully monitored for gastroesophageal
and gastropharyngeal refl ux or be treated empirically
with proton pump inhibitors or high dose H2-blockers.
Patients with recurrent or persistent laryngotracheal
stenosis must be assumed to have gastroesophageal
refl ux and be treated accordingly.
PATIENT EVALUATION
Clinical Evaluation
The degree of dysfunction and therefore the clinical
manifestations of tracheal stenosis vary widely. Patients
with tracheal stenosis may complain of shortness of
breath, dyspnea on exertion, stridor, hoarseness, dys-
phagia, aspiration, diffi culty clearing secretions, or any
combination of these symptoms and signs. Children
often have a history of recurrent croup or cardiopulmo-
nary problems.
In an offi ce setting, fl exible fi beroptic laryngoscopy
is essential to evaluate the site and degree of the steno-
sis, as well as vocal fold mobility. In a retrospective
review of pediatric cricotracheal resection, a multivari-
ate analysis revealed that unilateral or bilateral vocal
fold immobility was the only signifi cant risk factor for
failure of decannulation after airway reconstruction.13
Video laryngoscopy and still photographs provide objec-
tive documentation that can be discussed with the
patient and reviewed by other laryngologists (Fig. 70-1).
Administration of topical lidocaine instilled over the
glottis or by nebulization allows the endoscope to pass
through the glottis for visualization of the proximal part
of the trachea. This provides a good estimate of the
degree of stenosis but frequently may not be adequate
to ascertain the length of the narrowing because of an
inability to pass the scope through the entire length of
the stenotic segment. Passage of the scope through a
tight stenosis (>50% or higher than grade 2 in the
Cotton classifi cation) is not recommended in the offi ce
setting. Instrumentation of the airway may lead to
further iatrogenic narrowing and a potentially unstable
airway.
Figure 70-1. Flexible laryngoscopy demonstrating stenosis of the
subglottis and proximal part of the trachea (arrowheads).

Chapter 70
Management of Tracheal Stenosis
605
Direct laryngoscopy and rigid bronchoscopy using
rod-lens telescopes with the patient under general anes-
thesia complement the offi ce examination. Endoscopic
methods of quantifying the extent and severity of the
stenosis, as well as monitoring the success of treatment,
have been reported.14 Caretta and associates15 com-
pared preoperative fi ndings on endoscopy and com-
puted tomography (CT) with the intraoperative fi ndings
of 12 patients who underwent airway reconstruction.
They found that rigid endoscopy remains the most reli-
able tool for accurately assessing the length, extent, and
location of stenosis preoperatively. Tracheomalacia can
be diagnosed if the endoscopy is performed with the
patient breathing spontaneously.
Noninvasive methods of improving the diagnosis
and monitoring patients with airway stenosis are avail-
able and have a promising future; however, their practi-
cal role in the clinical setting remains unclear. Nouraei
and coworkers16 developed and tested a model based
on fl ow-volume loops that can be used to quantify the
mechanical extent and the clinical impact of laryngo-
tracheal stenosis.
Imaging
Xeroradiography provides exquisite defi nition of the
mucosal surface; however, this technique requires
greater radiation exposure and is not commonly avail-
able or used in the United States. In small children, soft
tissue radiographs may be suffi cient to localize and
grade the stenosis. Fluoroscopy is most helpful to
evaluate areas of tracheomalacia that collapse on
inspiration.
CT better ascertains the integrity of the cartilagi-
nous framework. Spiral CT with three-dimensional
reconstruction allows evaluation of the extent, shape,
and site of the stenosis (Fig. 70-2). During spiral CT the
patient is moved through the scanner gantry at a con-
stant rate, thus scanning continuously during a single
breath hold. This avoids artifacts introduced when the
imaging data are acquired during multiple breaths.
Three-dimensional reconstruction allows the possibility
of “virtual” endoscopy.17
Magnetic resonance imaging (MRI) is useful in the
evaluation of extensive laryngotracheal stenosis and
does not involve any radiation exposure. MRI allows
direct imaging in the sagittal and coronal planes, which
may be useful for planning treatment. A major limita-
tion, however, is that the patient must lie fl at and still
for a long time. This is not tolerated well by children
or by most adults with signifi cant tracheal stenosis. In
addition, MRI artifacts are created by cardiac and respi-
ratory movements. Ultrasound may also provide a con-
venient, well-tolerated, noninvasive method of assessing
the diameter of the subglottic airway.18
SURGICAL TECHNIQUES
Securing the airway is the cornerstone of all procedures
for correction of laryngotracheal stenosis. Intraopera-
tively, the airway may be secured with an endotra -
cheal tube, rigid bronchoscopy, jet ventilation, or a
tracheotomy.
Transoral or transnasal endotracheal intubation is
possible in patients who can be ventilated by mask or
in those with a stenosis that can be quickly dilated to
allow safe intubation. Patients who have a thin laryngo-
tracheal web are amenable to transendoscopic proce-
dures that will require minimal surgical manipulation
(i.e., less probability for postoperative edema) and may
therefore be intubated preoperatively. A tracheotomy
A
B
Figure 70-2. Axial (A) and sagittal (B) computed tomography scans (soft tissue algorithm) in a patient with laryngotracheal stenosis.
The tracheotomy is entering the airway just distal to the stenotic segment.

606
Section 7
Trachea and Mediastinum
performed under local anesthesia is recommended for
patients who have signifi cant airway compromise. The
tracheotomy should be performed in an area that will
not compromise the surgical procedure. We prefer to
incise the trachea at the level of the stenosis, thus
sparing the normal trachea from another injury. Usually,
this segment will be resected as part of the reconstruc-
tive surgery.
Jet-pressure ventilation (e.g., a Venturi system) is
usually ill advised because the stenosis implies restricted
outfl ow that may lead to tension pneumothorax. In
select patients, however, the stenosis can be bypassed
and outfl ow guaranteed with a rigid bronchoscope.
Gentle handling of tissues during surgery is funda-
mental in preventing postoperative edema and compro-
mise of the airway. The use of systemic corticosteroids
in the perioperative period, although their benefi t is
scientifi cally unproved, may help minimize the edema.
In addition, depot corticosteroids can be injected via a
laryngeal injector or a no. 22 butterfl y needle with 12-
inch tubing before dilatation. The dilatation is then
performed in sequential fashion. Corticosteroids
prevent intracellular sequestration and stabilize cell
membranes, thereby preventing the release of lyso-
somes that produce swelling and tissue destruction.
They also inhibit collagen synthesis, enhance collagen
breakdown, and reduce mitosis and the active transport
of fi broblasts. Empirically, intralesional injections may
be of benefi t to soften scar bands and synechiae.
Laryngotracheal surgery is classifi ed as a clean-
contaminated procedure, for which perioperative pro-
phylactic administration of antibiotics is recommended.
A prolonged therapeutic course of antibiotics may be
indicated for active chondritis. The theoretical value of
a prolonged course of antibiotics is to control infection,
thus stopping a vicious circle of chondritis, necrosis,
formation of granulation tissue, and scar deposition.
The diversity of surgical techniques is matched only
by the imagination of the surgeons dealing with laryn-
gotracheal stenosis. Treatment of laryngeal stenosis has
evolved from a “wait-and-see” philosophy to a proactive
approach that includes tracheotomy, dilatation, endo-
scopic procedures with microsurgery, and transcervical
approaches with single or multistaged reconstruction.
In an attempt to improve the outcome, surgery has
been combined with the use of antibiotics, stents, and
corticosteroids. Unfortunately, none of these surgical
techniques, singly or in combination, offers a 100% rate
of decannulation.
It should be noted that clinical studies addressing
different therapeutic options are limited by their retro-
spective, nonrandomized natures and by the lack of
standard defi nitions. Reports on the use of different
surgical methods and ancillary procedures, such as
stenting and steroids, have led to reports with opposite
fi ndings and conclusions.
Dilatation
Dilatation is most successful when used in patients with
thin, congenital webs. Acquired stenosis shows hyalin-
ization of connective tissue and collagen cross-linking
that commonly translate into an incompressible, rigid
scar. Thus, acquired stenosis generally implies a more
severe stenosis that resists dilatation.
However, the success rate of dilatation for acquired
stenosis improves when the technique is used for soft
or immature scars of minimal thickness and those
associated with Wegener’s granulomatosis19 and when
it is used as an adjunct to other techniques (e.g., laser
surgery).20 In addition, dilatation is useful in avoiding
a tracheostomy in patients with a stenosis that has not
“matured” or to prepare the lumen before tracheal
stenting.21 It may offer palliation to patients in poor
general medical condition. A signifi cant disadvantage
of the technique is the frequent need for repeated
dilatation. Overall, in approximately three quarters of
patients treated with dilatation as primary therapy,
the stenosis will recur and require a subsequent
intervention.22,23
We prefer to dilate with an expandable balloon
(CRE, Boston Medical) under full visualization via sus-
pension laryngoscopy.21 The patient can be intubated
or a bronchoscope can be introduced into the trachea
through a suspended laryngoscope (e.g., Dedo laryngo-
scope), thus maintaining a secure airway throughout
surgery.
Stenting
Technologic advances have allowed the design of stents
that can be inserted with relative simplicity and reliabil-
ity.24 The most popular stents are those made of silicone
(e.g., Dumon, Montgomery) or expandable metallic
mesh. Silicone stents provide palliation of airway obstruc-
tion but interfere with normal mucociliary clearance
and may become obstructed with secretions. Other
problems associated with silicone stents include migra-
tion, malposition, and the formation of granulation
tissue. Metallic stents made of various alloys have been
used for the long-term treatment of tracheal stenosis
secondary to acquired scarring, loss of tissue, and malig-
nancy. These stents include the Palmaz and Gianturco
made of stainless steel, the Wallstent made of cobalt,
and the Strecker and Ultrafl ex made of titanium or
nitinol. Metallic stents are expanded by balloon dilata-
tion or by inherent recoil. Those that expand by inher-
ent recoil have less risk of overexpansion and perforation
while maintaining fi xation against the tracheal wall.
Tracheal stenting is an ideal technique to palliate
signifi cant stenosis in patients who are not good surgi-
cal candidates. Stents are also useful during most airway
augmentation procedures to support a free graft or a
vascularized fl ap (Montgomery T tube, Eliachar stent,
Montgomery laryngeal stent) and to preserve the lumen
(Montgomery T tube). The reported ideal period of
stenting for this purpose is not well defi ned, but most
surgeons advocate stenting for 2 weeks to 10 months.
As a general rule, 2 to 6 weeks of stenting is suffi cient.
Although less invasive than transcervical approaches,
stenting is associated with signifi cant complications,
including dislocation of the stent, obstruction with

Chapter 70
Management of Tracheal Stenosis
607
granulation tissue, and perforation caused by ischemic
necrosis or erosion.21,24 Nouraei and coauthors25 noted
a highly signifi cant association between stent coloniza-
tion with specifi c bacteria (Staphylococcus aureus and
Pseudomonas aeruginosa) and the development of airway
granulation. Stenosis of the proximal subglottic area is
a relative contraindication to stenting. Because of its
proximity to the vocal folds, stents in this area cause
discomfort, coughing, and dysphonia.
Endoscopic Microsurgery
The success of endoscopic microsurgery depends on
the cause, site, and extent of the stenosis (i.e., diameter,
length); therefore, appropriate patient selection is
essential. Endoscopic microsurgery for acquired laryn-
gotracheal stenosis is likely to fail when used in patients
with multiple stenotic sites, when the stenosis is associ-
ated with loss of cartilaginous support, when it extends
for longer than 1 cm of the trachea or subglottis, when
the lesion is circumferential, and when it is accompa-
nied by the presence of bacterial infection.26
The use of topical mitomycin C, however, may
expand the indications for this approach.27-29 Mitomy-
cin C is an alkylating agent that inhibits protein and
DNA synthesis and is generally accepted as a safe and
cost-effective adjunct to laryngotracheal surgery.30 By
subsequently inhibiting fi broblast proliferation, mito-
mycin C decreases the likelihood of restenosis. Eliashar
and colleagues28 investigated the use of topical mitomy-
cin for the prevention of stenosis after acute injury to
the larynx in dogs. They were able to reduce the inci-
dence of stenosis from 85% to 27%. Rahber and
coauthors29 reported using topical mitomycin (at a
concentration of 0.4 mg/mL for 4 minutes) as an
adjunct to endoscopic laser surgery for laryngotracheal
stenosis. Nine of 12 (75%) patients with subglottic or
tracheal stenosis (or both) were decannulated via this
technique. Similarly, in a retrospective review of topical
mitomycin C, patients who were treated adjuvantly with
mitomycin C after endoscopic microsurgery experi-
enced a signifi cantly longer symptom-free interval than
did those who underwent endoscopic treatment alone
(23.2 versus 4.9 months).31
Endoscopic microsurgery with partial excision is an
ideal method for treating thin webs and less severe ste-
nosis. Multiple wedge excision or radial incisions of the
mucosal web augment the airway while still preserving
enough epithelium to prevent restenosis (Fig. 70-3).20
Topical
mitomycin
C
may
provide
additional
benefi t.27-31
Transcervical Procedures
Thick (>1 cm) and recurrent laryngotracheal stenoses
are better corrected via an external approach to
augment the lumen. The basic transcervical approaches
include tracheotomy, T tube placement, resection of
the stenotic segment with end-to-end anastomosis, and
laryngotracheoplasty. One of the most popular tech-
niques is augmentation with autologous free grafts.
Cartilage from the septum, thyroid alae, or ribs may be
harvested for use as a free graft. We prefer a rib graft
because it is abundant, thicker, and easy to carve
(Fig. 70-4). Other helpful augmentation techniques
involve the use of myoperiosteal32 or myocutaneous33,34
fl aps. Advocates of transcervical procedures believe that
these approaches allow precise excision of scar tissue,
facilitate primary healing by allowing the advancement
of local fl aps, and decrease the need for revision
surgery.
A
B
C
D
E
Figure 70-3. A to E, Radial wedge excision of a tracheal or subglottic web with the CO2 laser. Wedge excision at each quadrant augments
the airway and preserves enough epithelium to prevent restenosis. (A to C, From Bluestone CD, Stool SE [eds]: Atlas of Pediatric Otolaryngology. Phila-
delphia, WB Saunders, 1995, p 509.)
Posterior perichondrium
Resected portion
Perichondrium
Figure 70-4. Harvesting of the sixth rib through a horizontal inci-
sion over the preferred rib. The inner perichondrium is preserved to
provide suffi cient cartilage and avoid injury to the pleura with subse-
quent pneumothorax. The cartilage is then carved in lock-and-key
fashion. (From Bluestone CD, Stool SE [eds]: Atlas of Pediatric Otolaryngol-
ogy. Philadelphia, WB Saunders, 1995, p 470).

608
Section 7
Trachea and Mediastinum
Acquired tracheal stenosis may be segmental or cir-
cumferential. The corrective procedure should strive to
address the involved area while preserving adjacent
normal tissue. Several principles are fundamental to the
successful outcome of any surgery for laryngeal stenosis:
(1) a secure airway during the perioperative period,
(2) adequate exposure, (3) preservation of normal
tissue, and (4) prevention of recurrence by promoting
primary healing. Successful primary healing requires an
adequate blood supply and tension-free anastomosis.
The best approach for the management of exten-
sive tracheal stenosis is yet to be defi ned and must be
individualized to each patient. The most challenging
and controversial tracheal stenoses include those involv-
ing more than 50% of the length of the trachea; those
associated with extrinsic or intrinsic malignant obstruc-
tion, laryngeal stenosis, or tracheomalacia; and recur-
rent tracheal stenosis after resection of four or more
tracheal rings.
Laryngotracheal Reconstruction with
Cartilage Autografts
Reconstruction for combined tracheal and subglottic
stenosis can be achieved by anterior or posterior cricoid
grafting, or by both. In general, anterior augmentation
is usually recommended for moderate stenosis not
associated with signifi cant loss of cartilage and not
associated with posterior glottic stenosis. Posterior
augmentation is rarely used alone; rather, it is often
combined with anterior grafting for severe stenosis
(>75% of the lumen). However, in select pediatric
patients,
a
posterior
graft
may
be
inserted
endoscopically.
A horizontal incision following one of the skin
creases is made in the inferior aspect of the neck. The
incision is extended through subcutaneous tissue and
the platysma. Subplatysmal fl aps are elevated inferiorly
to the clavicle and superiorly to the hyoid bone. The
strap muscles are split in the midline to expose the
laryngotracheal complex. A vertical laryngofi ssure is
performed and extended into the upper two tracheal
rings (Fig. 70-5). The cricothyroid membrane may be
opened horizontally to facilitate lateral retraction of the
cricoid chondrotomy segments and insertion of the
graft. The mucosa is incised while preserving the ante-
rior commissure, and the posterior mucosal surface of
the larynx and trachea is exposed. It is important to
suture the tendon of the anterior vocal fold (anterior
commissure) to the anterior edge of the thyroidotomy.
A posterior cricoid chondrotomy is performed, with
preservation of the integrity of the cricoarytenoid joints
and postcricoid mucosa. If the posterior glottis is scarred
and stenotic, submucosal excision of the scar is per-
formed. A free cartilage graft is carved to fi t the poste-
rior cricoid area (Fig. 70-6). Kirschner wires are passed
into the graft to secure it in place. A similar technique
is used for the anterior graft (Fig. 70-7). Alternatively,
a rigid fi xation plate may be used to fi x the anterior
graft in place, which is carved to fi t in lock-and-key
fashion, as described by Zalzal and Cotton.35 The strap
muscles and platysma are reapproximated with absorb-
able suture. A soft rubber drain (e.g., Penrose) is left
in place. The skin is closed with staples and a compres-
sive dressing is applied.
Single-stage laryngotracheal reconstruction is pre-
ferred whenever possible and includes resection of
the anterior cricoid cartilage and posterior subglottic
mucosa (if involved by the scarring process).36-40 The
trachea is then cut into a design that fi ts into the defect;
the anterior cricoid is therefore replaced by tracheal
cartilage and the remaining posterior cricoid is relined
by the membranous trachea.
Myoperiosteal Flap
A sternocleidomastoid myoperiosteal fl ap, as described
by Friedman and Mayer,32 is an excellent alternative
technique for augmentation of the anterior cricoid ring
and cervical trachea. The surgical approach and expo-
sure are similar to those already described. The sterno-
clavicular origin of the left sternocleidomastoid muscle
is exposed through the cervical invasion and mobiliza-
tion of subplatysmal fl aps. If necessary (e.g., in a patient
A
B
Stay
sutures
Figure 70-5. A, Anterior cricoid split. B, Vertical laryngeal
and anterior tracheal incision. (A, From Bluestone CD, Stool SE
[eds]: Atlas of Pediatric Otolaryngology. Philadelphia, WB Saunders,
1995, p 470).

Chapter 70
Management of Tracheal Stenosis
609
A
B
Figure 70-6. A, Placement of wires through the
cartilage free graft as seen in an axial view with the
anterior and posterior cartilage grafts in place.
B, Kirschner wires (24 gauge) are inserted through
the cartilage grafts to stabilize them. An adaptation
plate may be used anteriorly.
A
B
Figure 70-7. Illustration (A)
and clinical photograph (B) of a
cartilage graft in place demonstrat-
ing the wiring technique used to
reconstruct an anterior tracheal
defect.

610
Section 7
Trachea and Mediastinum
A
B
C
D
Figure 70-8. A, Surgical exposure of the sternoclavicular head of the sternocleidomastoid muscle and the area of the stenosis. B, The peri-
osteum is elevated en bloc with the sternoclavicular head of the sternocleidomastoid muscle. C, The myoperiosteal fl ap is elevated. Branches
of the thyrocervical trunk supplying the inferior aspect of the sternocleidomastoid muscles are usually sacrifi ced to enhance mobility of the
fl ap. D, The myoperiosteal fl ap is sutured to the defect. A Montgomery T tube maintains the shape of the lumen and secures the airway.
with a long neck), a second horizontal incision is
performed closer to the clavicle. The sternal head is
transected, and the clavicular periosteum around the
lavicular insertion is incised and elevated as a myoperi-
osteal fl ap (Fig. 70-8A to C). Enough clavicular perios-
teum is included in the fl ap to cover the tracheal defect.
This fl ap is mobilized into the defect until tension-free
closure is achieved. The fl ap is sutured to the anterior
edges of the cricoid and trachea over a Montgomery T
tube (see Fig. 70-8D and E). The wound is closed in
multiple layers, a soft rubber drain is left in place, and
a compressive dressing is applied. The periosteum even-

Chapter 70
Management of Tracheal Stenosis
611
tually calcifi es, thus maintaining mechanical stability of
the lumen. A signifi cant advantage of this technique is
that harvesting of costal cartilage is not required. The
rotation of the sternocleidomastoid muscle, however,
produces a “bulge” deformity that may be unacceptable
for some patients, although it does diminish signifi -
cantly with time.
Resection and End-to-End Anastomosis
Patients with more severe stenosis or signifi cant loss of
structural support, or both, may require resection of
the stenotic segment. Exposure of the laryngotracheal
complex is achieved as previously described (in the fi rst
paragraph of Laryngotracheal Reconstruction), and the
trachea is dissected very close to its surface (Fig. 70-9).
If necessary, a full-thickness, circumferential segment of
the stenotic airway is resected while preserving as much
normal trachea as possible (Fig. 70-10). Identifi cation
of the recurrent laryngeal nerves is not necessary except
at their entrance to the larynx at the cricothyroid joints,
provided that the dissection is kept on tracheal
cartilage.
It is critical that the blood supply to the trachea be
preserved. Multiple branches from the inferior thyroid
artery penetrate the trachea at its posterior lateral
surface to provide a segmental blood supply consisting
of a segment of six rings.41,42 The thoracic trachea
receives branches from the subclavian, right internal
thoracic, and bronchial arteries.
E
Figure 70-8, cont’d E, The myoperiosteal fl ap has been sutured
to the defect.
Figure 70-9. Exposure of tracheal stenosis.
The airway is maintained with an anode tube in the
distal end of the trachea. It is useful to have sterile hoses
to connect the anode tube to the anesthesia ventilation
circuit to avoid having to exchange the connections
from the endotracheal tube to the anode tube beneath
the sterile drapes. Mobilization of the trachea is achieved
by separating the membranous trachea from the esoph-
agus posteriorly and by blunt dissection of the anterior
and lateral surfaces of the trachea (sparing the blood
supply). If needed, the suprahyoid musculature is tran-
Figure 70-10. Circumferential tracheal resection (specimen).

612
Section 7
Trachea and Mediastinum
sected from its insertion at the superior surface of the
hyoid bone.43 The anastomosis is then completed with
chromic 3-0 stitches (taper needle) for the mucosa and
submucosal Prolene 0 (or 28 wire) for the cartilage
(Fig. 70-11). The anode tube is removed and the endo-
tracheal tube is advanced into the trachea. A Prolene 1
stitch from the chin to the sternum is used to keep the
head in a fl exed position.
Preferably, if a large segment is to be resected, a
sliding tracheoplasty is performed.44,45 This technique
includes dividing the stenotic segment at the midpoint
of its length, incising the two opposing segments verti-
A
B
C
D
Figure 70-11. A and B, Sutures are placed through the mucosa so that the knots are outside the lumen. C, Sequential suturing of the mem-
branous trachea so that the knots are outside the lumen. D, Completed end-to-end anastomosis.

Chapter 70
Management of Tracheal Stenosis
613
cally, one anteriorly and the other one posteriorly, and
then sliding them together in a side-to-side anastomo-
sis.42 The length of the tracheal segment is shortened
by one half, thereby doubling the circumference and
quadrupling its luminal cross section.
If the lumen of the cricoid (subglottic) is involved,
cricotracheal resection is performed.46-50 The anterior
and lateral cricoid cartilage and subglottic mucosa are
resected. The posterior facet of the cricoid and the cri-
cothyroid joints are spared. The posterior subglottic
mucosa may be resected if scarred. The distal end of
the trachea is then transected in a shape that will fi t the
cricoid defect. The posterior mucosa will be replaced
by membranous trachea.
Despite refi nements in surgical techniques, such as
slide tracheoplasty and combined cervical and thoracic
approaches to release the bronchi and mobilize the
proximal part of the trachea, a signifi cant number
of patients have stenoses that are too extensive to
be treated with traditional surgical approaches.
In addition, combined transcervical-transmediastinal
approaches are highly invasive and involve mobiliza -
tion of the right hilum and pulmonary vessels,
division of the pulmonary ligament, and division and
reimplantation of the left main bronchus. Although
effective, the morbidity associated with this approach is
signifi cant.
Homograft transplantation and autotransplanta-
tion may soon be feasible alternatives for these
patients.51-55 The success of any grafting or transplanta-
tion depends on adequate vascularization, tension-
free anastomosis, and lack of an immune reaction
that would destroy the cartilaginous framework.
Hashimoto and colleagues52 assessed the feasibility of
achieving successful transplantation via immunosup-
pression. Kunachak and coworkers54 were able to
decannulate three of four patients with the use of cryo-
preserved, irradiated tracheal homograft. All these
patients had failed other conventional attempts at tra-
cheal reconstruction. The use of autografting with and
without revascularization with fl aps has also been
suggested.55
POSTOPERATIVE MANAGEMENT
Patients are transferred to an intermediate or intensive
care unit for continuous monitoring and frequent tra-
cheotomy care. Whenever an end-to-end anastomosis is
performed, tension is avoided in the immediate postop-
erative period by maintaining the head in a fl exed posi-
tion. A Prolene 1 stitch from the mentum to the sternum
serves to secure this position. Patients are kept with the
head of the bed elevated at 30 degrees to diminish the
possibility of gastric refl ux and to facilitate ventilation.
Humidifi ed air is delivered by face or tracheotomy
mask, accordingly. This is critical to avoid crusting and
facilitate mobilization of tracheobronchial secretions.
Delivery of oxygen via a T tube attachment to the tra-
cheostomy tube is not recommended because it exerts
traction on the tracheotomy tube, thereby eliciting pain
and cough. Furthermore, this traction may break the
peristomal sutures and lead to gross contamination of
the wound with tracheal secretions.
Patients are not fed during the fi rst 24 hours after
surgery to diminish the possibility of nausea and vomit-
ing, which may stress the repair. A nasogastric tube
for suctioning the stomach contents during the initial
postoperative period is recommended for the same
purpose.
The tracheotomy tube may be downsized or
changed to a cuffl ess tube 72 hours after the procedure.
This allows the formation of a tract that greatly facili-
tates insertion of the second tube. In cases in which an
external approach was used, such as a laryngofi ssure, it
is prudent to keep a cuffed tracheotomy tube in place
for 5 to 7 days to prevent massive subcutaneous emphy-
sema and contamination of the cervical wounds when
air and secretions are insuffl ated through the endo-
laryngeal wound.
The patient should be able to breathe and protect
the airway from aspiration before the tracheotomy tube
is removed. Clinical signs such as an ability to tolerate
a plugged tracheotomy tube and the absence of bron-
chorrhea, choking, or other signs of aspiration suggest
that the patient is ready to be decannulated. Examina-
tion with a fl exible laryngoscope is an invaluable adjunct
to ascertain adequacy of the airway and the pharyngeal
phase of swallowing, as well as to monitor the healing
process.
Patients who need a long-term tracheotomy tube or
T tube stent should be trained in the care of these arti-
fi cial airways. The caregivers or companions of these
patients must be aware of the possible complications
and be profi cient in emergency maneuvers such as
removal and reinsertion of the tracheotomy tube. In
the case of T tube stents, caregivers or companions
should be instructed on removal of the stent and inser-
tion of a tracheotomy tube.
COMPLICATIONS
Early complications consist of prolonged intubation
secondary to glottic edema or edema in the area of the
anastomosis, as well as superfi cial infection. Suture
granulomas in the tracheal incision occur occasionally,
and removal of these granulomas by repeated bron-
choscopy may be necessary. Grillo and associates47
described a series of patients who had diffi culty with
deglutition or aspiration postoperatively. All eight
patients had undergone extensive resection, including
suprahyoid laryngeal release in four of them. One
patient required a gastrostomy tube for treatment, and
some patients also had diminished vocal quality or pro-
jection after surgery.
Granulation tissue at the suture line was the most
common problem early in Grillo and colleagues’ series
and necessitated repeat bronchoscopy and, occasion-
ally, injection of triamcinolone through an endoscope
into the base of the removed granulation tissue.47 Since
the introduction of absorbable Vicryl suture, the
problem of anastomotic granulation has markedly
decreased or is absent.

614
Section 7
Trachea and Mediastinum
5. Nordin U, Linholm CE: The trachea and cuff-induced tracheal
injury: An experimental study on causative factors and preven-
tion. Acta Otolaryngol 96(Suppl 345):1-71, 1977.
6. Whited RE: A study of postintubation laryngeal dysfunction.
Laryngoscope 95:727-729, 1985.
7. Whited RE: A study of endotracheal tube injury to the subglottis.
Laryngoscope 95:1216-1219, 1985.
8. Bryce DP: The surgical management of laryngotracheal injury. J
Laryngol Otol 86:547-587, 1972.
9. Caldarelli DD, Friedberg SA, Harris AA: Medical and surgical
aspects of the granulomatous diseases of the larynx. Otolaryngol
Clin North Am 12:767-781, 1979.
10. Alaani A, Hogg RP, Drake Lee AB: Wegener’s granulomatosis and
subglottic stenosis: Management of the airway. J Otolaryngol Otol
118:786-790, 2004.
11. Mair EA: Caution in using subglottic stents for Wegener’s
granulomatosis. Laryngoscope 114:2060-2061, author reply 2061,
2004.
12. Gaynor EB: Gastroesophageal refl ux as an etiologic factor in
laryngeal complications of intubation. Laryngoscope 98:972-979,
1988.
13. White DR, Cotton RT, Bean JA, et al: Pediatric cricotracheal
resection. Arch Otolaryngol Head Neck Surg 131:896-899, 2005.
14. Nouraei SAR, McPartlin DW, Nouraei SM, et al: Objective sizing
of upper airway stenosis: A quantitative endoscopic approach.
Laryngoscope 116:12-17, 2006.
15. Carretta A, Melloni G, Ciriaco P, et al: Preoperative assessment
in patients with postintubation tracheal stenosis. Surg Endosc
20:905-908, 2006.
16. Nouraei SAR, Winterborn C, Nouraei SM, et al: Quantifying the
physiology of laryngotracheal stenosis: Changes in pulmonary
dynamics in response to graded extrathoracic resistive loading.
Laryngoscope 117:581-588, 2007.
17. Glueckner T, Lang F, Bessier S, et al: 2D and 3D CT imaging
correlated to rigid endoscopy in complex laryngo-tracheal steno-
ses. Eur Radiol 11:50-54, 2001.
18. Lakhal K, Delplace X, Cottier J, et al: The feasibility of ultrasound
to assess subglottic diameter. Anesth Analg 104:611-614, 2007.
19. Lebovics RS, Hoffman GS, Leavitt RY, et al: The management of
subglottic stenosis in patients with Wegener’s granulomatosis.
Laryngoscope 102:1341-1345, 1992.
20. Shapshay SM, Beamis JF Jr, Hybels RL, et al: Endoscopic treat-
ment of subglottic and tracheal stenosis by radial laser incision
and dilatation. Ann Otol Rhinol Laryngol 96:661-664, 1987.
21. De Mello-Filho FV, Moody-Antonio S, Carrau RL: Endoscopically
placed expandable metal tracheal stents for the management
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22. Clement P, Hans S, de Mones E, et al: Dilatation for assisted
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laryngotracheal
stenosis.
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23. Herrington HC, Weber SM, Andersen PE: Modern management
of laryngotracheal stenosis. Laryngoscope 116:1553-1557, 2006.
24. Carrau RL: Use of stents in head and neck surgery. Curr Opin
Otolaryngol Head Neck Surg 13:105-106, 2005.
25. Nouraei SAR, Petrou MA, Randhawa PS, et al: Bacterial coloniza-
tion of airway stents. Arch Otolaryngol Head Neck Surg 132:1086-
1090, 2006.
26. Simpson GT, Strong MS, Healy GB, et al: Predictive factors of
success or failure in the endoscopic management of laryngeal
and tracheal stenosis. Ann Otol Rhinol Laryngol 91:384-388,
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27. Perepelitsyn I, Shapshay S: Endoscopic treatment of laryngeal
and tracheal stenosis: Has mitomycin C improved the outcome?
Otolaryngology Head Neck Surg 131:16-20, 2004.
28. Eliashar R, Eliachar I, Esclamado R, et al: Can topical mitomycin
prevent laryngotracheal stenosis? Laryngoscope 109:1594-1600,
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29. Rahbar R, Shapshay SM, Healy GB: Mitomycin: Effects on laryn-
geal and tracheal stenosis, benefi ts, and complications. Ann Otol
Rhinol Laryngol 110:1-6, 2001.
30. Ubell ML, Ettema SL, Toohill RJ, et al: Mitomycin-C application
in airway stenosis surgery: Analysis of safety and costs. Otolaryngol
Head Neck Surg 134:403-406, 2006.
PEARLS
• Tracheal stenosis may originate from a wide variety
of etiologic factors; however, the pathogenesis
typically involves a mucosal or cartilaginous injury
(or both) leading to scarring, loss of structural
support, and an infl ammatory reaction.
• Multiple factors play a role in the development of
tracheal stenosis after endotracheal intubation, but
cuff pressure appears to be the most signifi cant.
• Intraoperative control of the airway is paramount in
any surgery for laryngotracheal stenosis.
• Endoscopic microsurgical techniques, with or
without adjunctive procedures such as intralesional
steroid injection or application of mitomycin C, are
ideally suited for management of thin webs or other
less severe stenoses with good cartilage support.
• Poor candidates for major reconstructive surgery
may best be managed by repeated dilatation or
stenting.
PITFALLS
• Failure to control gastroesophageal refl ux in the
perioperative period may contribute to recurrent or
persistent laryngotracheal stenosis.
• In the offi ce setting, passing a fl exible scope through
a signifi cant tracheal stenosis may lead to airway
compromise and a clinically unstable situation.
• Severe or recurrent stenoses are often not amenable
to conservative endoscopic therapy and usually
require tracheal resection with cartilage graft
reconstruction or end-to-end anastomosis for
defi nitive management.
• Although tracheal stents provide a less invasive
option for patients with associated malignancy or
comorbid medical conditions, stenting can result in
signifi cant complications such as dislocation or
migration, obstruction with granulation tissue, and
perforation.
• Compromising the blood supply to the trachea
during resection and reconstruction may lead to
postoperative complications such as wound
dehiscence and restenosis.
References
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birth weight neonates: Indications and outcomes. Laryngoscope
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Management of Tracheal Stenosis
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Chapter 71
Management of Tracheocutaneous Fistula
and Depressed Scar
Eugene N. Myers
A tracheocutaneous fi stula is a sequela of tracheotomy
and is usually associated with an unsightly depressed
tracheotomy scar. Formation of this fi stula is predicated
on squamous epithelium migrating from the skin into
the trachea, forming an epithelial interface with the
mucosa of the trachea, and thereby creating a true
fi stula that cannot close spontaneously. Marked separa-
tion of the strap muscles associated with a prolonged
indwelling cannula, infection, and wasting of subcuta-
neous tissue are important factors predisposing to the
development of a depressed scar and fi stula. These fea-
tures facilitate epithelial migration toward the tracheal
mucosa along the tract formed by the tracheostomy
cannula. The relationship between the duration of tra-
cheostomy and the development of a persistent fi stu-
lous tract has been well established, with a fi stula rate
of 50% being identifi ed in patients with a cannulation
time of longer than 1 year.1,2
Persistence of a tracheocutaneous fi stula may lead
to increased morbidity, particularly in children with
limited pulmonary reserve. White and Smitheringale
have listed “pneumonia or even drowning occurring as
a result of aspiration of liquid through the fi stula par-
ticularly while the infant is bathing. Mucus and saliva
expelled from the trachea can present a hygiene
problem and an embarrassing social situation. Lastly, if
of suffi cient size, the persistent tracheocutaneous fi stula
may interfere with the child’s speech.”3
A persistent tracheocutaneous fi stula may also con-
tribute to reduced pulmonary function in patients with
underlying pulmonary disease.4 Eaton and colleagues5
stated that a persistent tracheocutaneous fi stula in chil-
dren may be a source of considerable morbidity because
of problems with poor hygiene, aspiration, respiratory
infection, and associated speech diffi culty.
In addition to problems with the fi stula, wide,
unsightly scars often follow tracheostomy as secondary
healing occurs after decannulation. Many emergency
tracheostomies are still carried out through a vertical
incision, which itself may result in an unsightly scar or
a keloid.
Closure of a tracheocutaneous fi stula was reported
as early as 1934 by Jackson and Babcock.6 They used a
lined bipedicle fl ap reinforced with conchal cartilage.
Pressman reported repair of a depressed tracheostomy
scar by detaching and transposing the origins of the
sternocleidomastoid muscle into the defect.7 Bishop
and coworkers suggested rotation of the sternohyoid
muscle and closure of the stoma with a turnover fl ap of
skin based at the inferior margin of the tracheostomy
site.8 Lewis and colleagues described the use of a sub-
cutaneous Z-plasty in which fat and platysma muscle
were incorporated to provide additional soft tissue bulk
and to take tension off the suture line.9
During performance of a tracheostomy, the strap
muscles are retracted laterally and the cannula is
inserted. In a patient who has had a cannula in
place for a prolonged period, infection and fi brosis
occur and the strap muscles are scarred into a position
lateral to the tracheotomy. When the patient is eventu-
ally decannulated and the stoma heals by secondary
intention, the skin heals directly to the trachea, thus
forming a depressed scar without a tracheocutaneous
fi stula.
Several methods for closure of a tracheocutaneous
fi stula have been described, including primary closure,
fi stulectomy with primary closure in layers, and fi stulec-
tomy with healing by secondary intention. The use of
electrocautery in the management of fi stulas in the
pediatric group has been described.5 When a fi stula is
too large to be closed by secondary intention, a second-
ary surgical procedure is necessary. Lee and associates
described closure of a large tracheocutaneous fi stula
with a turnover hinge fl ap and a V-Y advancement fl ap
617

618
Section 7
Trachea and Mediastinum
in two patients who had undergone tracheostomy
during conservation partial laryngectomy.10
Our technique emphasizes restoring the natural
anatomic position of the strap muscles in the midline.
This key feature has eliminated the need for the afore-
mentioned procedures. Kulber and Passy described a
similar technique that prevents reattachment of the
skin to the trachea by reapproximation of the strap
muscles in the midline.11
White and Smitheringale suggest that epithelial
migration of skin into the trachea and extensive cicatri-
cial resolution of chronic granulation tissue result in
the formation of a dense connective tissue sleeve based
around the entire opening of the tracheal stoma. They
state that “this condition is responsible for diffi cult
tracheotomy changes, decannulation problems and
aphonia in children.”3 It has been stated that intralumi-
nal extension of this tracheal keloid may easily be
underestimated during bronchoscopy; therefore, more
recent recommendations for surgical management
include complete revision of the tracheostomy sinus
tract, followed by either decannulation or closure of the
tracheostomy.12 White and Smitheringale suggest several
methods of closure of the tracheostomy site in chil-
dren.3 In one, the fi stula is excised, the base is closed
in pursestring fashion and inverted into the fi stulous
tract, and the wound is closed in two or three layers with
or without closure of the strap muscles in the midline.
The fi stulous tract and scar are sharply excised down to
the level of the tracheostoma, including any intralumi-
nal component. The trachea is then closed with silk or
sometimes wire, followed by a three-layer closure of the
strap muscles, subcutaneous tissue, and skin. They also
describe a procedure involving excision of the epitheli-
alized tract, including any intraluminal extension noted
at bronchoscopy, followed by temporary replacement
and early removal of a small tracheotomy tube.
PATIENT SELECTION
Patients selected for this procedure usually have had
tracheostomy cannulas in place long-term. After decan-
nulation, an unsightly depressed scar is fi xed to the
trachea and moves every time that the patient swallows.
Such movement may occur with or without a fi stulous
tract (Fig. 71-1). Children with pneumonia or aspira-
tion of liquid through the fi stula are certainly examples
of those who would benefi t from this procedure. Dis-
charge of mucus and saliva from the trachea presents a
problem with hygiene and is a source of embarrassment
to old and young alike. Patients with a tracheocutane-
ous fi stula, particularly children, will fi nd that their
voice will be stronger after closure of the fi stula.
PREOPERATIVE PLANNING
Complications may occur after closure of a tracheocu-
taneous fi stula, particularly in children, so it is of utmost
importance to ensure that the caliber of the trachea is
satisfactory before closure. One reason for persistence
of the fi stula may be that the patient does not have an
adequate airway and the fi stula serves as an auxiliary
airway. The concern is that once the fi stula is closed in
such patients, the airway might not be patent enough
to permit adequate air exchange.
The airway should always be evaluated before
closure of a tracheocutaneous fi stula to ensure an ade-
quate lumen. Laryngoscopy and tracheoscopy are
appropriate techniques for such evaluation. Particular
attention should be directed to the superior aspect of
the stoma because this area is the most common site of
granuloma formation, which may occlude the airway in
children. In adults, simple closure of the fi stula should
not interfere with the airway. Computed tomography is
an alternative approach to evaluate the adequacy of the
tracheal lumen, particularly if closure under local anes-
thesia is being contemplated.
SURGICAL TECHNIQUE
In adults, the fi stula may be excised and the scar revised
in a single-stage procedure under local anesthesia with
intravenous sedation. The patient is placed in the supine
position with the head extended. A transverse incision
is made at the level of and extending somewhat lateral
to the tracheocutaneous fi stula (Fig. 71-2). The skin
fl aps are widely undermined. The scar between the skin
and the fi stula should then be released. Dissection is
carried down along the fi stula to the level of the trachea.
The tract should then be excised, with just enough skin
left to close the fi stula by inverting the squamous epithe-
lium so that it forms the inner epithelial surface of the
anterior wall of the trachea (Fig. 71-3).
The strap muscles will be found incorporated in
dense scar tissue and adherent to the lateral aspect of
the trachea. The strap muscles are then dissected free
from the scar tissue (Fig. 71-4) and repositioned over
the trachea to restore them to their normal anatomic
position. The muscles are next sutured together in the
midline with absorbable suture (Fig. 71-5). This maneu-
ver effectively separates the trachea from the skin and
Figure 71-1. A tracheocutaneous fi stula resulted from long-term
placement of a tracheostomy cannula.

Chapter 71
Management of Tracheocutaneous Fistula and Depressed Scar
619
Figure 71-2. The scar from the tracheotomy is excised almost down
to the fi stula.
Figure 71-3. Dissection is carried down to the surface of the fi stula,
and the skin of the fi stulous tract is used as a skin fl ap. It is turned
in to restore the anterior epithelial lining of the trachea.
Figure 71-4. The skin fl aps superior/inferior to the incision are
undermined, and the strap muscles are dissected free of the
trachea.
prevents reformation of the depressed scar. The subcu-
taneous tissue is closed without tension. The skin inci-
sion is then closed with 6-0 chromic suture. A Z-plasty
or a geometric broken-line skin closure may be used if
necessary to produce a small, smooth scar. Steri-Strips
rather than a dressing should be applied to the wound
to minimize tension.
A modifi cation of this technique is also used for
patients who have a depressed tracheotomy scar without
a tracheocutaneous fi stula (Fig. 71-6). The mechanism
of the depressed scar with adherence to the trachea is
similar; of course, the only step that is unnecessary is
excision of the fi stula. The procedure results in an
acceptable scar (Fig. 71-7). Returning the strap muscles
to their anatomic position eliminates the depressed scar
and prevents its recurrence.
Potential complications of repair include pneumo-
mediastinum, pneumothorax, and respiratory insuffi -
ciency requiring tracheotomy.13 Complications occurred
in patients who underwent single-stage excision and
closure of the tracheocutaneous fi stula associated with
large defects of the anterior tracheal wall. The authors
therefore modifi ed their technique for larger defects as
follows. The tracheocutaneous fi stula and scar are
excised by means of a horizontal elliptical excision. The
fi stulous tract is dissected down to the anterior tracheal
wall and divided. If the defect in the anterior wall is
greater than 4 mm, a no. 3 or 4 metal Pilling tracheot-
omy tube is inserted into the previous tracheotomy site.
The strap muscles are elevated and closed in the midline
around the tracheotomy tube with 4-0 polyglactin. The
skin edges are widely undermined and then closed
around the tracheotomy tube with 5-0 nylon suture.
The tracheotomy tube is plugged in the recovery room
or on the fi rst postoperative day and the patient decan-
nulated on day 2. The small central area is allowed to
heal by secondary intention.
In children, this procedure is done under general
anesthesia by using the least complex method of closing
a tracheocutaneous fi stula, which consists of excising
the epithelium of the fi stulous tract and allowing the
tract to close by secondary intention. Such closure
occurs rapidly and results in a watertight seal that will
allow the patient to swim and bathe. This method is
recommended for young children in particular because

620
Section 7
Trachea and Mediastinum
A
B
C
Figure 71-5. A to C, The strap muscles are repositioned in the
midline and sutured together. The subcutaneous tissue and skin are
then closed.
A
B
Figure 71-6. A and B, The depressed scar, without a fi stula, is
managed in similar fashion.
A
B
Figure 71-7. The improved cosmetic result after excision of the
tracheocutaneous fi stula (A) and revision of the depressed scar (B).
more extensive procedures may require lengthy anes-
thesia and manipulation of the trachea may lead to
edema and airway obstruction. If the scar is not satisfac-
tory, it may be revised later.14
POSTOPERATIVE MANAGEMENT
Perioperative antibiotics are administered to prevent
infection because the fi stula is colonized by potentially
pathogenic organisms. Adult patients are usually hospi-
talized overnight for observation of the airway and dis-
charged the next day. Care of the wound is minimal
because the skin is closed with absorbable 6-0 catgut skin

Chapter 71
Management of Tracheocutaneous Fistula and Depressed Scar
621
sutures and Steri-Strips, which are removed in 7 to 10
days. Typically, no further wound care is required.
Infants or children who undergo this procedure are best
monitored in an intensive care unit overnight to ensure
adequacy of the airway. A tracheotomy set should be
kept at the bedside in the event of airway obstruction.
COMPLICATIONS
We have not experienced any complications in adult
patients undergoing this procedure. There are numer-
ous reports, however, of children who have undergone
this closure only to have airway distress that has resulted
in severe complications and required reopening of the
wound to establish an airway.
Wheeler and associates described four patients, the
eldest of which was 31 months of age, who experienced
severe respiratory distress within 24 hours of primary
closure of the fi stula and who required emergency
care.15 These patients had pulmonary disease and
appeared to be at increased risk because of high trans-
mural airway pressure with forceful coughing. The
authors also call attention to the potential for pneumo-
pericardium or pneumoperitoneum in addition to the
subcutaneous emphysema that they noted.
Keenan and coworkers also reported four cases, the
fi rst two of which illustrate the complications that might
arise with primary closure of the fi stulous tract.16 In
their fi rst patient, a problem arose when they attempted
to obtain an airtight, watertight seal with meticulously
layered closure. The airway distress experienced by this
patient prompted the authors to modify their proce-
dure to include simple excision of the fi stulous tract
and allow the wound to heal by secondary intention.
PEARLS
• Patients in the pediatric age group should be
evaluated endoscopically to ensure that the airway
is patent before closure of a tracheocutaneous
fi stula.
• Computed tomography may be useful in evaluating
the airway before closing a tracheocutaneous fi stula.
• The procedure should be done under local
anesthesia with intravenous sedation in adults as a
safety measure and to avoid the possibility of
subcutaneous emphysema after extubation.
• The key feature of the operation is dissecting the
strap muscles free of scar tissue and the trachea and
restoring normal anatomy by reapproximating the
strap muscles in the midline. This reinforces the
closure in patients with a tracheocutaneous fi stula
and eliminates the depressed scar in all patients.
• Children undergoing closure of a tracheocutaneous
fi stula should be monitored in the intensive care
unit after the procedure because airway distress may
be a complication of this procedure.
• Adult patients should be observed in the hospital
overnight to ensure that the airway is stable.
PITFALLS
• Patients, particularly those in the pediatric age
group, may experience respiratory distress after
closure of a tracheocutaneous fi stula.
• Tracheocutaneous fi stulas are colonized by bacteria,
so perioperative antibiotics should be given to
prevent infection.
• Failure to thoroughly free the strap muscles from
scar tissue and the trachea and to reapproximate
the muscles in the midline will result in persistence
of the depressed scar.
• Failure to provide airtight closure of the fi stulous
tract and provision of an inner epithelial lining will
result in recurrence of the fi stula.
References
1. Joseph HT, Jani P, Preece JM, et al: Paediatric tracheostomy:
Persistent tracheo-cutaneous fi stula following decannulation. Int
J Pediatr Otorhinolaryngol 22:231-236, 1991.
2. Wetmore RF, Handler SD, Potsic WP: Pediatric tracheostomy.
Experience during the past decade. Ann Otol Rhinol Laryngol
91:628-632, 1981.
3. White AK, Smitheringale AJ: Treatment of tracheocutaneous fi s-
tulae in children. J Otolaryngol 18:49-52, 1989.
4. Licameli GR, Marsh BR, Tunkel DE: A simple method for closure
of tracheocutaneous fi stula in children. Arch Otolaryngol Head
Neck Surg 123:1066-1068, 1997.
5. Eaton DA, Brown OE, Parry D: Simple technique for tracheocu-
taneous fi stula closure in the pediatric population. Ann Otol
Rhinol Laryngol 112:17-19, 2003.
6. Jackson C, Babcock WW: Plastic closure of tracheocutaneous
fi stula. Surg Clin North Am 14:199-221, 1934.
7. Pressman JJ: The repair of depressed tracheostomy scars. Arch
Otolaryngol 74:150-152, 1961.
8. Bishop JB, Bostwick J, Nahai F: Persistent tracheostomy stoma.
Am J Surg 140:709-710, 1980.
9. Lewis VL Jr, Manson PN, Stalnecker MC: Some ancillary proce-
dures for correction of depressed adherent tracheostomy scars
and associated tracheocutaneous fi stulae. J Trauma 27:651-655,
1984.
10. Lee BJ, Goh EK, Wang SG, Hwang SM: Closure of large tracheo-
cutaneous fi stula using turn-over hinge fl ap and V-Y advancement
fl ap. J Laryngol Otol 116:627-629, 2002.
11. Kulber H, Passy V: Tracheostomy closure and scar revisions. Arch
Otolaryngol 96:22-26, 1972.
12. Friedberg J: Tracheotomy revisions in infants: To facilitate extu-
bation and restore phonation. Int J Pediatr Otorhinolaryngol
13:61-68, 1987.
13. Drezner DA, Cantrell H: Surgical management of tracheocutane-
ous fi stula. Ear Nose Throat J 77:534-537, 1998.
14. Myers EN, Stool SE: Complications of tracheotomy. In Myers EN,
Stool SE, Johnson JT (eds): Tracheotomy. New York, Churchill
Livingstone, 1985, pp 147-169.
15. Wheeler WB, Kurachek SC, Lobas JG, Lipscomb TS: Respiratory
complications of tracheocutaneous fi stula closure. Crit Care Med
19:580-582, 1991.
16. Keenan JP, Snyder GG 3rd, Lehmann WB, Ruiz JW: Management
of tracheocutaneous fi stula. Arch Otolaryngol 104:530-531,
1978.

Chapter 72
Stenosis of the Tracheostoma Following
Total Laryngectomy
Eugene N. Myers
Stenosis of the tracheostoma following laryngectomy is
an infrequent but distressing complication that may
occur despite meticulous attention to the construction
of the tracheostoma. Stenosis usually occurs in the early
months following laryngectomy but may also occur
years later. Wax and colleagues defi ned tracheal steno-
sis as a narrowing of the stoma that requires the patient
to wear a stent (usually a laryngectomy cannula) for
longer than 3 months after surgery or requires revision
of the tracheal stoma.1 Giacomarra and associates
defi ned tracheostomal stenosis as respiratory insuffi -
ciency at rest or during exercise or if there is diffi culty
in clearing tracheal secretions because of nonlaminar
fl ow, or both.2 Although the patient with relatively good
pulmonary function may maintain adequate exercise
tolerance, many patients with emphysema or chronic
obstructive lung disease may encounter respiratory
insuffi ciency3 with stenosis of the tracheostoma. Ade-
quate mucociliary transport may be impeded by stomal
stenosis and may result in stagnation of mucus and the
potential for recurrent pulmonary infection. Severe ste-
nosis is potentially dangerous because complete obstruc-
tion may occur in the presence of crusting or a mucous
plug, particularly during an episode of tracheitis or
tracheobronchitis.4 Stomal stenosis will also interfere
with proper insertion and use of a tracheoesophageal
puncture speech prosthesis.
CAUSATIVE FACTORS
The following factors contribute to stomal stenosis:
• Radiation therapy
• Wound dehiscence with healing by secondary
intention
• Inadequate excision of peristomal skin and fat at the
time of initial stomal construction
• Devascularization of the trachea
• Infection after surgery
• Hypertrophic scarring
• Excessive scar tissue formation
• Peristomal recurrence of cancer
Prevention of stomal stenosis should be a part of
preoperative planning and should include meticulous
surgical technique and diligent postoperative care.
Patients who have risk factors for tracheostomal stenosis
need special attention to prevent this problem.
In the case of extensive resection of additional
tracheal rings for adequate tumor clearance, careful
construction of the tracheostoma with appropriate
fl ap design may minimize tension and prevent tracheo-
cutaneous dehiscence, which would ultimately lead to
concentric scarring and stenosis.
Patients who have had a preliminary tracheostomy
for airway obstruction days or weeks before surgery
usually develop extensive local infl ammatory response
and colonization with bacteria in the peristomal skin.
This skin and a tracheal ring below the stoma should
be excised with the specimen in order to prevent post-
operative infection. Patients who are markedly obese
may have bulging of tissues into the stoma, resulting in
a form of pseudostenosis.
Stomal stenosis may be encountered following radi-
ation therapy, particularly when the peristomal area is
included in the radiation portal, such as in patients with
subglottic extension of cancer who are at risk for stomal
recurrence. Local fl ap transposition may help prevent
this concentric scar formation and, ultimately, prevent
stenosis.
The primary objectives in the prevention of trache-
ostomal stenosis are related to surgical technical aspects
such as careful approximation of skin and mucous
623

624
Section 7
Trachea and Mediastinum
membrane, elimination of extensive compressive forces
and active tension on the stoma margin, increasing the
diameter of the stoma, and redistribution of the forces
of scar contraction.5
The following are technical modifi cations:4,6-8
• Oblique section of the tracheal stump to increase
stomal diameter, therefore forming an oval rather
than a circular stoma
• Excision of peristomal fat
• Complete skin coverage of the cut edge of the tra-
cheal cartilage with through-and-through or vertical
mattress sutures
Clairmont,9 Jatho,10 Isshiki and Tanabe,11 Trail and
colleagues,12 and Hartwell and Dykes13 describe a variety
of similar techniques using Z-plasty, double-V, and V-Y
fl ap design methods of primary tracheostomal construc-
tion at the time of laryngectomy, thereby enlarging the
stoma and redirecting the forces of scar contraction.
Vlantis and associates described a method of primary
reconstruction of the stoma designed to prevent stomal
stenosis.14 They had a series of 260 patients over a 10-
year period, only 6% of whom developed a stenosis of
the stoma. Interestingly, 76% of the patients had prior
radiation therapy and 73% received a vocal prosthesis
at the time of surgery. Their technique was said to be
simple and makes best use of the natural supportive
function of tracheal cartilage and basic surgical
principles.
Postoperatively, when tracheostomal stenosis has
developed, it may be managed by conservative means
or by surgical correction. The nonsurgical technique
involves dilatation with progressively larger laryngec-
tomy tubes and constant use of one of a variety of tra-
cheostomy stents. This may not be satisfactory in some
patients, because removal of the tube or button, for
even a few hours, may result in rapid restenosis. In
patients who have been heavily irradiated, however, this
form of management may be useful, because surgical
management of heavily radiated tissues may predispose
toward loss of surrounding skin and restenosis. An addi-
tional drawback to stenting with a stoma button is that
the presence of a tracheotomy valve or button may
preclude the use of the valve in patients with a tracheo-
esophageal puncture.
Sani has described the CO2 laser stomaplasty for
tracheostomal stenosis.15 This technique includes ablat-
ing a triangular area on each side of the tracheostoma.
The areas ablated include the rim of the stoma. These
denuded areas then heal by secondary intention. The
procedure had to be repeated in three out of eight
patients in this series. Seven of eight patients eventually
attained a satisfactory stoma that did not require
cannulation.
Bretteville and associates reported a series of 20
consecutive patients with stenosis of the tracheostoma
following total laryngectomy.16 The authors described
their experience with 280 laryngectomies with an inci-
dence of stenosis of 7%. Their technique is based on
the principle of multiple Y-V plasties, usually under local
anesthesia. They incised previous scars and created
small pointed skin fl aps that are aligned with tracheal
incisions. No tissue is removed and all of the denuded
area is covered by skin or mucosa.
Numerous authors have reported their methods of
revision of the tracheostoma. Montgomery4 classifi ed
the common types of stenosis as (1) vertical slit, (2)
concentric, and (3) inferior shelf. He described sepa-
rate procedures for the correction of these individual
problems. Converse17 and Maruyama and colleagues18
also described variations of the Z-plasty technique for
this problem. Giacomarra and associates described a
technique for the correction of tracheostomal stenosis,
combining radial incisions, V-shaped fl aps, and inter-
posing fl aps.2 Wax and colleagues, in a series of 43
patients with tracheostomal stenosis, used a variety of
techniques including advancement fl aps, Z-plasties, and
V-Y insetting.19 All three of these techniques had a
greater than 90% success rate when used primarily.
One of these 11 failed patients had a successful revision
using one of the other techniques.
PATIENT SELECTION
Patients who develop postoperative stomal stenosis are
usually given a trial of treatment using plastic stents or
laryngectomy tubes. This procedure involves the use of
an uncuffed tube that fi ts snugly into the stenotic stoma.
After wearing the tube for approximately 1 week, the
patient returns to have the next larger tube inserted.
This progressive gentle dilatation continues until the
patient has a caliber matching that of the no. 8 laryn-
gectomy tube. The patient should wear a tube con-
stantly for 6 months. During the day, a soft silastic stent
with the posterior aspect fenestrated makes it possible
to use the speaking valve. If the patient has an adequate
airway at that time, then no surgery is required.
However, if the stoma restenoses, then the patient
should be given the option of having surgical interven-
tion. Patients who have had very high doses of radiation
to the stoma should be managed conservatively, if pos-
sible, because radiation interferes with healing and pre-
disposes to tissue loss and restenosis. Every effort should
be made to rule out peristomal recurrence of cancer.
SURGICAL TECHNIQUE
The forces of scar contracture predispose to stenosis in
healing of a circular wound. The most common problem
producing stenosis is a band of scar tissue that concen-
trically narrows the stoma (Fig. 72-1). The caliber of the
trachea inferior to the scar band is usually normal. The
goals of the revision procedure are to excise the con-
centric scar and prevent it from recurring. The common
features for all techniques are (or should be) (1) to
eliminate circular forces of contraction and (2) to
provide for healing by primary intention (e.g.,
skin-mucosa).
The operation may be done with the patient under
local or general anesthesia. A rolled-up blanket is placed