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Stenosis of the Tracheostoma Following Total Laryngectomy
Introduction
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 can result from a variety of factors and usually occurs in the early months following laryngectomy. However, stenosis may also occur years later despite the type of closure performed at initial surgery. Wax et al. defined tracheal stenosis 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. Giacomarra et al. defined tracheostomal stenosis as respiratory insufficiency at rest or during exercise or if there is difficulty in clearing tracheal secretions because of nonlaminar flow, or both. 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 insufficiency when stenosis of the tracheostoma occurs. Adequate mucociliary transport may be impeded by stomal stenosis and may result in stagnation of mucus and the potential for recurrent pulmonary infection. Severe stenosis is potentially dangerous because complete obstruction may occur in the presence of crusting or a mucous plug, particularly during an episode of tracheitis or tracheobronchitis. Stomal stenosis may also interfere with the proper insertion and use of a tracheoesophageal puncture speech prosthesis. Stenosis can occur regardless of the type of closure or reconstruction. A wide variety of techniques have been described to address stenosis ranging from noninvasive techniques, such as serial dilation or excision of peristomal adipose tissue, to more invasive techniques, such as Z-plasties, local or advancement flaps, and even free flaps for recalcitrant stenosis. The common features for all techniques are (1) to eliminate circular forces of contraction and (2) to provide for healing by primary intention (e.g., skin to mucosa) ( Fig. 24.1 ).
Key Operative Learning Points
- 1.
Stenosis of the tracheostoma is a potential complication of total laryngectomy despite the type of closure performed at the initial creation of the stoma.
- 2.
The goals of surgery are to eliminate circular forces of contracture and allow for healing by primary intention.
- 3.
Care must be exercised if patient has received, or is planning on receiving, radiation therapy to the stoma site; however, previous radiation therapy does not preclude revision of the tracheostoma, provided the stoma was not included in the radiation portal.
Preoperative Period
History
- 1.
The patient may present with any or all of the following symptoms:
- a.
Increasing shortness of breath at rest or with exercise
- b.
Inability to clear tracheal secretions
- c.
Recurrent pulmonary infections
- d.
Inability to properly use a tracheoesophageal puncture speech prosthesis
- a.
- 2.
Patient history
- a.
Timing of laryngectomy to onset of symptoms
- 1)
Stenosis typically occurs in the first several months after surgery, although it may present years later.
- 1)
- b.
Extent of primary surgery
- 1)
Extensive resection of tracheal rings may lead to excessive tension on the stoma if not carefully designed.
- 1)
- c.
Type of primary closure
- d.
Local wound care at home
- e.
History of radiation therapy
- 1)
Radiation involving the stoma increases the risk of stenosis as is seen in patients with subglottic extension of the tumor.
- 1)
- f.
Trial of serial dilation by increasing laryngectomy tube size
- a.
- 3.
Risk factors for tracheostomal stenosis
- a.
Peristomal recurrence of cancer
- b.
Radiation therapy
- c.
Wound dehiscence with healing by secondary intention
- d.
Inadequate excision of peristomal skin and adipose tissue at the time of initial stomal construction
- e.
Devascularization of the trachea
- f.
Infection after surgery
- g.
Hypertrophic scarring
- h.
Diabetes mellitus
- i.
Poor nutritional status
- a.
Physical Examination
- 1.
Recurrence of cancer must be excluded first as a cause for the above-mentioned symptoms.
- a.
This may include careful inspection, imaging, and/or biopsy.
- a.
- 2.
Careful note of the diameter of the stoma must be made.
- a.
Markedly obese patients may have bulging of tissues into the stoma, resulting in a form of pseudostenosis.
- a.
- 3.
Examine surrounding soft tissue for breakdown of skin edges.
- 4.
Palpate for the presence of a high-riding innominate artery.
- 5.
Ensure that the trachea inferior to the concentric scar band is of adequate caliber.
Imaging
- 1.
Imaging is not typically required prior to correction of stenosis of the laryngostoma.
Indications
- 1.
Symptomatic dyspnea at rest or with activity
- 2.
Inability to clear secretions
- 3.
Inability to provide adequate pulmonary toilet
- 4.
Inability to use tracheoesophageal puncture speech prosthesis
Contraindications
- 1.
No absolute contraindications other than severe comorbidities
- 2.
Radiation is a relative contraindication.
- a.
Patients who have had radiation therapy in which the radiation portals include the stoma should be treated by nonsurgical means.
- b.
Operative repair can still be performed if meticulous technique is used in patients in whom the radiation portals did not include the stoma.
- a.
Preoperative Preparation
- 1.
Patients who had a tracheostomy prior to their laryngectomy often develop local inflammatory response and colonization with bacteria in the peristomal skin.
- a.
The peristomal skin and a tracheal ring below the stoma should be excised in these patients to prevent postoperative infection.
- a.
- 2.
A review of the radiation portals must be undertaken to be sure that the stoma has not been radiated.
- 3.
Careful planning must be undertaken to not damage a preexisting tracheo esophageal puncture (TEP).
- 4.
Imaging is not typically required prior to correction of tracheostomal stenosis.
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