A Case of Refractory Tracheocutaneous Fistula Successfully Treated With the Combination of Auricular Cartilage Grafting and Sternocleidomastoid Muscle Flap.

Abstract

The tracheotomy site usually closes spontaneously after decannulation, but in rare cases, it develops into tracheocutaneous fistula. We experienced a case of tracheocutaneous fistula that was successfully treated with the combination of auricular cartilage grafting and sternocleidomastoid muscle flap. In this case, we performed the closure of tracheocutaneous fistula with a view to filling the tissue defect with soft tissue to prevent recurrence. The surgical procedure performed in this case was unique, which to our knowledge, has not been described previously. Herein, we report some findings obtained, together with a literature review. The patient was a 73-year-old male. Starting five months after tracheotomy, the closure of a tracheocutaneous fistula was attempted twice at an otolaryngology clinic, which resulted in recurrence. The patient visited our department with the desire to close the tracheocutaneous fistula. At the initial examination, we found a cutaneous fistula with a diameter of approximately 2 mm on the cranial side of the sternal notch and thinning of the surrounding tissue. Preoperative computed tomography (CT) showed a tracheal defect with a size of approximately 10 mm on the caudal side of the sternal notch. The surgery was performed under general anesthesia 10 months after tracheotomy. The platysma muscle was attached to elevate the skin flap, and the scarring at the cutaneous fistula opening was removed. The cartilage defect was 10×12 mm in size. A piece of cartilage was harvested from the posterior surface of the auricle (navicular fossa) and grafted to the tracheal opening. A part of the left sternocleidomastoid muscle body of the sternal head was dissected from the mandibular side using the sternal attachment site as a stalk and elevated. The muscle flap was rotated, with its tip folded back, doubled over, and fixed on top of the auricular cartilage graft. The platysma muscles were sutured togetherduring whichthe skin flap suture line was shifted so that the suture line would not coincide with the tracheal fistula site. The course was favorable, with no recurrence for three years. In the closure of a tracheocutaneous fistula, two sides need to be considered: the trachea and the skin. The tracheal defect in the present case was larger than 10 mm in sizeand thusauricular cartilage grafting was performed. In addition, we filled the tissue defect with the soft tissue of a sternocleidomastoid muscle flap, which was a uniquestep. The combined use of auricular cartilage grafting and sternocleidomastoid muscle flap was effective for the closure of a refractory tracheocutaneous fistula.