Comments
The etiology of tracheostoma stenosis may be related to one or more
of the following factors:
1. Incorrect stoma construction at the time of laryngectomy.
2. Excessive scar tissue due to infection or fistula near the stoma or repeated trauma by cannulas.
3. Absent or defective tracheal rings at the stoma. (Stoma recurrence of carcinoma is regarded as having a totally different etiology and therefore not part of this discussion.)
The first reason is probably the most important. Preventive measures at the time of the surgery and in the direct postoperative period are the most valuable tools in the maintenance of a tracheostoma with an appropriate size and can avoid multiple reconstruction procedures. In our experience the best results are obtained when it is possible to create the stoma in the inferior skin flap, using a separate fenestra in the skin as described in the chapter on primary puncture (see chapter on Tracheostoma construction).
Once a stoma has started to form fibrous tissue leading to stenosis, it is extremely difficult to arrest this process, and such a patient may be condemned to the use of a stoma button or cannula for all or much of the time. A reconstruction of the tracheostoma should then be considered. As mentioned above, stoma revision may also be a part of a tracheoesophageal (TE) fistula closure after which a stable fistula can be created after secondary puncture. The same procedure might be considered in certain patients, who have recurrent problems with granulation tissue, thickening of the wall, and resultant inward displacement and even “disappearance” of the prosthesis8 as well as chronic widening of the TE fistula.
1. Incorrect stoma construction at the time of laryngectomy.
2. Excessive scar tissue due to infection or fistula near the stoma or repeated trauma by cannulas.
3. Absent or defective tracheal rings at the stoma. (Stoma recurrence of carcinoma is regarded as having a totally different etiology and therefore not part of this discussion.)
The first reason is probably the most important. Preventive measures at the time of the surgery and in the direct postoperative period are the most valuable tools in the maintenance of a tracheostoma with an appropriate size and can avoid multiple reconstruction procedures. In our experience the best results are obtained when it is possible to create the stoma in the inferior skin flap, using a separate fenestra in the skin as described in the chapter on primary puncture (see chapter on Tracheostoma construction).
Once a stoma has started to form fibrous tissue leading to stenosis, it is extremely difficult to arrest this process, and such a patient may be condemned to the use of a stoma button or cannula for all or much of the time. A reconstruction of the tracheostoma should then be considered. As mentioned above, stoma revision may also be a part of a tracheoesophageal (TE) fistula closure after which a stable fistula can be created after secondary puncture. The same procedure might be considered in certain patients, who have recurrent problems with granulation tissue, thickening of the wall, and resultant inward displacement and even “disappearance” of the prosthesis8 as well as chronic widening of the TE fistula.
