Introduction
The construction of a stable tracheostoma during laryngectomy is essential for successful prosthetic voice rehabilitation. A tracheostoma should be large enough to make the use of a cannula superfluous, but small enough to be easily occluded by the patient for speech production. In addition to this there are several other properties, which the stoma should possess in order to facilitate speech rehabilitation. This chapter seeks to examine the major surgical considerations in constructing, maintaining or reconstructing the stoma to this end.
Stenosis of the tracheostoma after laryngectomy can be a frustrating complication, which may occur shortly after the operation or after several months. Stoma stenosis has no accepted definition, but the incidence in the literature varies between 4% and 41%.1-3 Montgomery4 has classified stenosis into three types: vertical-slit, concentric and inferior-shelf type. This may have some merit, although most of the cases of stenosis cannot be classified strictly into one type or another. Some authors consider a stoma stenotic when a cannula is needed.5 There is some rationale for the concept that a stoma with a cross-sectional area less than that of the glottis at rest may be considered too narrow.6 Severe stenosis may not only interfere with the clearing of secretions or crusts from the trachea leading to airway obstruction, but is also troublesome in relation to prosthetic voice rehabilitation. The effects of stenosis may be aggravated by the use of non-indwelling prostheses, since they protrude from the tracheoesophageal (TE) fistula through the stoma. This problem can be avoided with the application of indwelling voice prostheses. The effectiveness of these prostheses has improved considerably over the last few years due to new designs and materials.7-9 Nevertheless, these prostheses still have to be replaced regularly.
Generally, the replacement procedure can be accomplished safely and simply in an out-patient clinic setting. However, stenosis may complicate this so that general anesthesia may be required. In addition, if a cannula has to be worn, it can be more difficult or sometimes impossible to achieve a seal over the stoma, thus resulting in air escape, which interferes with speech quality. Also the use of external speech valves and the use of heat moisture exchangers10,11 may be more complicated, or impossible. Reconstruction of a stenotic stoma is therefore a procedure, which might be necessary even if the patient has no complaints of retention of secretions or breathing problems, but desires prosthetic voice rehabilitation.
Stenosis of the tracheostoma after laryngectomy can be a frustrating complication, which may occur shortly after the operation or after several months. Stoma stenosis has no accepted definition, but the incidence in the literature varies between 4% and 41%.1-3 Montgomery4 has classified stenosis into three types: vertical-slit, concentric and inferior-shelf type. This may have some merit, although most of the cases of stenosis cannot be classified strictly into one type or another. Some authors consider a stoma stenotic when a cannula is needed.5 There is some rationale for the concept that a stoma with a cross-sectional area less than that of the glottis at rest may be considered too narrow.6 Severe stenosis may not only interfere with the clearing of secretions or crusts from the trachea leading to airway obstruction, but is also troublesome in relation to prosthetic voice rehabilitation. The effects of stenosis may be aggravated by the use of non-indwelling prostheses, since they protrude from the tracheoesophageal (TE) fistula through the stoma. This problem can be avoided with the application of indwelling voice prostheses. The effectiveness of these prostheses has improved considerably over the last few years due to new designs and materials.7-9 Nevertheless, these prostheses still have to be replaced regularly.
Generally, the replacement procedure can be accomplished safely and simply in an out-patient clinic setting. However, stenosis may complicate this so that general anesthesia may be required. In addition, if a cannula has to be worn, it can be more difficult or sometimes impossible to achieve a seal over the stoma, thus resulting in air escape, which interferes with speech quality. Also the use of external speech valves and the use of heat moisture exchangers10,11 may be more complicated, or impossible. Reconstruction of a stenotic stoma is therefore a procedure, which might be necessary even if the patient has no complaints of retention of secretions or breathing problems, but desires prosthetic voice rehabilitation.