INDICATIONS

A rare late complication of tracheostomy is persistence of a stoma 3 to 6 months after removal of the tracheostomy tube. The frequency of this complication ranges widely from 3.3% to 29%. A persistent tracheal stoma usually develops when the tracheostomy tube has been left in position for a prolonged period, permitting epithelialization between the skin and the tracheal mucosa. Kulber and Passy have reported that a fistula does not develop when the period of cannulation is less than 16 weeks, but the incidence increases to 70% when the cannulation period is greater than 16 weeks. Patients who are malnourished, have been on high doses of steroids, or who have had infection around the stoma are particularly at risk for developing this complication. Granulomatous disease, prior radiation treatment, and distal obstruction such as bilateral vocal cord paralysis or tracheal stenosis are other risk factors.

When the tracheostomy tube is removed, the fistula lumen often rapidly narrows down to a dry fistula tract with inverted skin edges, but then it fails to improve further and close. When the epithelial-lined tract has formed from the trachea to the skin, the opening will persist although wound contracture might result in a significant narrowing of the orifice. Although less morbid when compared with some of the other late complications of tracheostomy such as a tracheoesophageal fistula or tracheal stenosis, persistent tracheal stomas are nonetheless troublesome. Patients may suffer from recurrent aspiration with resulting respiratory infection and ineffective cough and clearance of respiratory secretions. Unsatisfactory phonation, skin irritation and breakdown from chronic exposure to oral secretions, and intolerance to submersion also provide clear indications for surgical correction.

CONTRAINDICATIONS

Need for ongoing mechanical ventilatory support

Moderate or severe tracheomalacia

Chronic cough or recent upper respiratory tract infection

Need for endotracheal suctioning to maintain pulmonary toilet

Decannulation of tracheostomy in the previous 3 to 6 months

PREOPERATIVE PLANNING

It is essential to perform direct laryngoscopy and bronchoscopy before an attempt is made to close a persistent tracheal stoma to evaluate and rule out other tracheal pathology such as bilateral vocal cord paralysis, tracheomalacia, tracheal stenosis, or distal airway obstruction such as peristomal granulation tissue.

Determine with bronchoscopy whether the patient would have a difficult intubation. Failure to do so may result in unexpected respiratory arrest, or need for placement of emergent tracheostomy tube.

SURGERY

Techniques

A simple one-stage method of closure has been described that immediately provides an epithelialized internal surface of the trachea. A circular incision is made around the stoma, raising the margins of the flap but not sufficiently to destroy the blood supply (Fig. 41.1). This ring of tissue is then inverted and the stoma is closed with a running subcuticular suture of fine catgut (Fig. 41.2

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