Closure Of Tracheostoma Research Articles

64 Tracheostoma closure surgery - what problems arise?

64 Tracheostoma closure surgery - what problems arise?

A Novel Dressing Method to Achieve Early Natural Tracheostoma Closure.

Tracheotomy is a routine surgical procedure in oral and maxillofacial surgery. After decannulation, spontaneous tracheostoma closure is usually expected. However, wound healing is often delayed, requiring 1 to 2 weeks for healing and resulting in the need for surgical closure. Although many reports have described the surgical closure of a tracheostoma, few reports have focused on the dressing methods for closure of tracheal openings after decannulation. Herein, the authors report a new tracheostoma closure method that does not rely on surgical closure or the adhesive strength of the tape. The authors' conventional dressing method was to place gauze over the tracheostoma after decannulation and apply pressure through elastic tape or with a film dressing to seal the tracheostoma and achieve natural closure by reducing the leakage of air and tracheal secretions. However, the conventional method cannot completely prevent the leakage of air and tracheal secretions. We developed a novel method to achieve early closure by markedly reducing the leakage by partially inserting the gauze into the tracheostoma.

Tracheostoma Closure Technique Using Three Local Flaps.

When a tracheostoma is no longer needed, the opening normally closes spontaneously after cannula removal, but some cases require tracheostoma closure. This procedure has been well described, but must be performed in such a way as to minimize its invasiveness and complications while securing a high closure rate. Our procedure for conducting tracheostoma closure technique involves the creation of two hinge flaps and one cover flap to close the tracheostomy opening. We reviewed the medical records of 23 patients (12 men, 11 women; mean age 60.0 SD19.7years) who underwent tracheostoma closure technique between 2001 and 2019. Surgery was indicated for patients in whom closure had not occurred after conservative monitoring for ≥ 2months following cannula removal. The surgical procedure began by raising two hinge flaps on either side of the tracheostomy opening, turning the skin surface to the luminal side to form the anterior tracheal wall. Rather than a single layer of skin, multiple skin layers were sutured together to prevent air leakage from between hinge flaps. A further cover flap was produced to cover the anterior tracheal wall, closing the tracheostomy opening. Postoperatively, the tracheal lumen was observed via fiberscopy. No stenosis of the tracheal lumen occurred in any patients, and the tracheocutaneous fistula was successfully closed in all cases. Tracheostoma closure technique using hinge flaps to reconstruct the anterior tracheal wall and a cover flap as a skin flap to cover the skin defect appears useful for patients with failure of spontaneous tracheocutaneous fistula closure.

Safety of percutaneous dilatational tracheotomy (PDT) with the rigid tracheotomy endoscope (TED): a 6-month follow-up multicenter investigation

BackgroundThe rigid tracheotomy endoscope (TED) was recently introduced to improve the fiberoptic technique during percutaneous dilatational tracheotomy (PDT) in critically ill patients. The aim was to evaluate the long-term complications of PDT using TED equipment in a prospective multicenter investigation.MethodsOne hundred eighty adult patients underwent PDT using TED in four German hospitals. Patients who were alive or their guardians were contacted via telephone and interviewed using a structured questionnaire 6 months following the tracheostomy procedure. Patients with airway complaints were invited for outpatient clinical ENT examination. The incidence of adverse events related to PDT was registered.ResultsOf 180 patients who received tracheostomy, 137 (76.1%) were alive at the time of follow-up. None of the 43 lethal events was related to the PDT. Fifty-three (38.7%) patients were available for follow-up examination, whereas 14 (10.2%) were able to visit ENT physicians. Two (3.8%) out of 53 patients developed tracheocutaneous fistula with required surgical closure of tracheostoma. Dyspnea (7.5%), hoarseness (5.7%), stridor and swallowing difficulties (both with 3.8%) were the most common complaints. Tracheal stenosis was confirmed in 1 patient (1.88% [95% CI: 0.33; 9.93]).ConclusionThe use of TED for PDT in the clinical setting is safe regarding adverse events at 6-month follow-up. The incidence of tracheal stenosis after PDT with TED is comparable with that of flexible bronchoscopy; however, its role for PDT at the intensive care unit should be clarified in further investigations.

Age at Decannulation after Pediatric Tracheostomy.

Background: Parents of tracheostomized infants often enquire when their children will undergo decannulation. However, there are few studies on the decannulation of children who are tracheotomized in infancy. Therefore, this study investigated when decannulation should be performed in children by retrospectively analysing medical records. Methods: We performed a retrospective chart review of tracheostomy, decannulation and tracheostoma closure in 48 children who underwent tracheostomy before the age of 3 years. The indications for tracheostomy included upper airway obstruction, neurological conditions, cardiopulmonary conditions, craniofacial conditions and trauma. Result: Nineteen (33.3%) patients were decannulated during the follow-up period: 12 had upper airway obstruction, four had cardiopulmonary conditions, one had a neurological condition and two had craniofacial conditions. The average age at tracheostomy was 13.6 months. The average age at the start of the decannulation therapy was 5.4 years. The average age at decannulation was 7.2 years. The average age at tracheostoma closure was 9.2 years. Conclusion: This description of ages at decannulation after pediatric tracheostomy may be useful when explaining the prognoses and timelines of decannulation to parents and caretakers of pediatric patients who need to undergo tracheostomy.

Tracheal surgery in Germany

: First attempts of tracheal surgery in Germany were made in 1881 and tracheal resection was performed in dogs. First experiences in tracheal for malignant tracheal stenosis with tracheal resection and end-to-end anastomosis in humans were published in 1915 by the same surgeons. In 20th century several techniques of tracheal mobilisation and coverage of the anastomosis were developed to enable sufficient end-to-end anastomosis. Uniportal thoracoscopic techniques and extracorporal membrane oxygenation are progresses established more or less recently in the last decade. We performed a literature research in PubMed concerning tracheal surgery and evaluated data from the “Federal Statistical Office Germany”. In the later we requested extraction of data from the German diagnosis-related-groups (G-DRG)-system database concerning procedures and diagnoses affecting tracheal resection and management of tracheal injury. In 2018 in Germany, 267 patients were treated for neoplasm of the trachea and 66 patients for tracheal injury of the pars thoracica. Acquired tracheal stenosis was diagnosed in 1070 patients and tracheal stenosis after medical intervention in 740 individuals. There was no distinct difference in the number of cases of these diagnoses between 2014 and 2018. The most common tracheal operation in Germany is the closure of tracheostoma, which was performed almost 5,000 times per year between 2014 and 2018. Treatment of tracheal stenosis was mainly bronchoscopic. Most frequent method was the dilatation of the stenosis without implantation of a stent in 314 cases, followed by bronchoscopic excision of tissue in 119 patients. Surgical management consisted of resection of tracheal stenosis with end-to-end anastomosis in 72 cases in 2018. Management of tracheal neoplasm was with multimodal predominantly. The management of tracheal diseases is predominately performed by bronchoscopic procedures. This affects the diagnostic procedures, as well as the therapeutic interventions. It is conspicuous that there is a lack between the number of encoded diagnoses in every field of tracheal diseases and the number of encoded diagnostic and therapeutic procedures. The reason for this circumstance is unclear.

Fascia Temporalis Free Flap for Cricotracheal Reconstruction: A Novel Approach

The aim of tracheal reconstruction is to provide an airtight and noncollapsible airway covered with a suitable epithelial lining. To date, no ideal treatment is available for large tracheal defects. We report 4 patients who underwent one-stage reconstruction for a cricotracheal stenosis with a free temporoparietal fascia flap and costal cartilage grafts. Closure of tracheostoma was achieved for all patients. The main advantage of this flap compared with the free radial forearm flap is that it supplies a more suitable lining allowing the reepithelialization process with respiratory epithelium. This one-stage procedure provides a reliable construct to substitute for large tracheal defects, even in areas previously exposed to an operation or radiotherapy.

A case of eclampsia complicated by cerebral haemorrhage and iatrogenic hypopharyngeal oedema and haemathoma

Introduction. Eclampsia, serious complication of preeclampsia, can further be complicated by intracranial haemorrhage. Cesarean section under general anesthesia represents an additional risk factor. Case report. We present a case of 22 years old primipara in the 38th gestational week who after a sudden occurrence of a headache, within one hour developed eclampsia. Emergent Caesarean section was undertaken; she was intubated after several attempts. Severe tongue and hypopharyngeal edema and haemathoma made the extubation impossible; she remained intubated, sedated, mechanically ventilated, on antioedematous, anticonvulsive, antihypertensive therapy. On the third postoperative day, tracheostomy was performed. On the sixth day, she complained of a headache and visual disturbances. Neurological examination revealed left-sided hemiparesis. Multislice computed tomography showed intracranial hemorrhage. It was not until the closure of tracheostoma (eleventh day) that her blood pressure normalized and the headache ceased. Four days later she was dismissed from the hospital with improved clinical state. Conclusion. In order to avoid sudden and unexpected, but serious complications of preeclampsia/eclampsia, we emphasize the need of searching for more subtle signs of the disease, of prompt radiologic diagnosis and aggressive blood pressure control, with a prepared strategy for difficult airway management.

Management of tracheostoma closure in pediatric patients

Management of tracheostoma closure in pediatric patients

The role of supracricoid laryngectomy for glottic carcinoma recurrence after radiotherapy failure: a critical review

Conclusions.In the near future salvage supracricoid laryngectomy (SCL) will be used more extensively for failures of radiotherapy for glottic carcinoma. Objectives. Primary radiotherapy has been used for patients with early glottic carcinomas in northern Europe and North America for more than half a century. Local recurrences after radiotherapy for glottic malignancies occur in 5–25% for T1 carcinomas and in 15–50% for T2 carcinomas. The classic choice as salvage surgery in cases of glottic squamous cell carcinoma recurrence after irradiation failure is total laryngectomy. The development of extended conservation procedures such as SCL has permitted an increasing number of successful partial laryngectomies that save laryngeal functions after radiotherapy failure. SCL allows the creation of a neo-larynx, permitting both swallowing and speech; in most cases the tracheostoma can be closed. Methods. The electronic database Pubmed was searched without publication date limits. Results. Considering available data (103 cases), 84.5% of the cases treated with salvage SCL for irradiation failure did not present a new local recurrence; laryngeal recurrences after salvage SCL (15.5%) were successfully treated with total laryngectomy in 66.7% of the cases. Tracheostoma closure was possible in all except two cases after a mean period ranging between 12 and 28 days. Swallowing results seemed good, with longer recovery time in irradiated than in non-irradiated patients who underwent SCL. Voice quality determined with psychoacoustic methods had acceptable intelligibility.

Ejnell法による声門開大術が奏功した小児の先天性両側喉頭麻痺症例

Bilateral vocal fold paralysis is a relatively rare laryngeal disease in infants. This condition causes dyspnea, therefore, long-term airway management including tracheal intubation and tracheostomy is necessary. Several surgical techniques have been proposed to restore laryngeal obstruction, however, a generally accepted therapeutic strategy for children has not been established. In this article, a girl who had bilateral congenital vocal fold paralysis was successfully treated by Ejnell's operation. She underwent intubation for severe respiratory distress immediately after the birth. Bilateral vocal fold fixation at midline position was diagnosed by endoscopic observation of the larynx. A tracheostomy was performed when she was 6 months old. Thereafter, laterofixation of the right vocal fold described by Ejnell was carried out at the age of 7-years resulting in a successful closure of tracheostoma. This operation is simple, safe and less traumatic, and it should be considered as a choice for surgical intervention for children with bilateral vocal fold fixation.

Management of tracheal wall resection for thyroid carcinoma by tracheocutaneous fenestration and delayed closure using auricular cartilage.

In the case of advanced thyroid carcinoma invading the trachea, surgical procedures for tracheal resection are selected in relation to the degree of invasion. We created a tracheocutaneous fenestration that was later closed with a free auricular cartilage autograft. We present a simple and effective method for permanent closure of tracheostoma. The surgical procedure for delayed closure consists of three steps: (1) preparing the hinge flap with additional undermining of the subcutaneous layer and the strap muscles; (2) removing a portion of the conchal cartilage from the auricle, which is easily performed with a semicircular skin incision along the anthelix of the ear; and (3) placing the conchal cartilage with its convex surface upward just over the sutured hinge flap layer. Under local anesthesia, we successfully employed this reconstructive procedure for 5 patients. Unfortunately, however, in one patient, we had to reopen the closed tracheocutaneous fenestration on the second postoperative day because of an acute problem that was independent of the closure surgery. Four patients remain in satisfactory condition for more than 2 years since the closure of tracheostoma. The auricular cartilage free graft is a relatively simple procedure which supplies tracheal wall skeletal support for the permanent closure of the tracheocutaneous fenestration.

Secondary tracheoesophageal puncture

Tracheoesophageal puncture is a common and reliable method of surgical speech rehabilitation in laryngectomy patients who do not have satisfactory esophageal speech. The surgical procedure is simple and reproducible. It has minimal complications and can be done under ambulatory conditions. Silicon shunt prosthesis and tracheostoma valves have reduced the main drawbacks of esophageal speech, preventing aspiration and finger tracheostoma closure. Tracheoesophageal puncture is a common and reliable method of surgical speech rehabilitation in laryngectomy patients who do not have satisfactory esophageal speech. The surgical procedure is simple and reproducible. It has minimal complications and can be done under ambulatory conditions. Silicon shunt prosthesis and tracheostoma valves have reduced the main drawbacks of esophageal speech, preventing aspiration and finger tracheostoma closure.

気管口閉鎖前後の呼吸様式の変化 換気量，換気時間，血液ガスの検討

In the field of respiratory physiology, it seems interesting to evaluate the change of respiratory pattern as the results of alteration of the respiratory route before and after the closure of tracheostoma.Tracheostomized patients breathe without the upper airway such as the nose, the mouth and the larynx. When tracheostoma is closed, the patients are suddenly forced to breathe through the upper airway. As the result, an anatomical dead space, a respiratory resistance and a humidifying function are added to their airway abruptly. The purpose of this study was to examine the above-mentioned change of respiratory pattern before and after the closure of tracheostoma.The subjects were seven tracheostomized patients with normal lung function. Tidal volume, respiration time and blood gases were measured before and just after, 1 hour and 2 hours after the closure of tracheostoma.The results were as follows: 1) When tracheostoma was closed, tidal volume and respiration time increased and respiratory minutes volume tended to decrease gradually in the course of time. 2) While Pao2 did not change in the course of time before and after the closure of tracheostoma, Paco2 was increased slightly after the closure and the value continued in 2 hours almost constantly.These changes were statistically significant except for minutes volume.It is obvious that the anatomical dead space increases when the tracheostoma is closed. As the results, the efficiency of ventilation would decrease.Our results showed, however, Pao2 did not decrease after closing the tracheostoma. On the other hand, respiratory minutes volume tended to decrease, and Paco2 increased just after the closing it and the value continued constantly for two hours.These results confirm that the ventilatory efficiency would be improved sometimes after the closure of tracheostoma in spite of the increased dead space, suggesting that the humidifying function and the resistance of the upper airway play a significant role in the respiration.

Spontaneous flow measurements of laryngotracheal resistance in 30 tracheostoma patients

The airway resistance of 30 patients with stenosis in the region of the larynx and upper trachea was assessed by means of the spontaneous flow method. For this purpose, the measuring head of a spontaneous flow rhinomanometer (A 440 rhinomanometer, Allergopharma, Reinbek, FRG) was adapted to the new conditions. Laryngotracheal airway resistance between 1.8 and 30 mbar/l/s was registered. This method proved to be suitable for measuring the airway resistance of the larynx and upper trachea in tracheostoma patients with varying degrees of stenosis. Thus, a further objective parameter has been added to those of inspection and X-rays for reviewing the indications for tracheostoma closure.