Tracheostoma Closure Technique Using Three Local Flaps

Abstract

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 SD19.7 years) who underwent tracheostoma closure technique between 2001 and 2019. Surgery was indicated for patients in whom closure had not occurred after conservative monitoring for ≥ 2 months 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.

Background

When a tracheostoma is no longer needed, the opening normally closes spontaneously after cannula removal. In the few cases without spontaneous closure, tracheostoma closure technique is required. This procedure has been well described, but must be performed so as to minimize both invasiveness and complications, while securing a high closure rate. Closure by simple suture is common, but entails a high risk of mediastinal emphysema, pneumothorax, and wound opening. Our procedure for tracheostoma closure involves the creation of two hinge flaps and one cover flap to close the tracheocutaneous fistula. We describe this procedure and its outcomes herein.

Patients and Methods

Patients

The patients were 23 individuals (12 men, 11 women; mean age, 60.0 SD19.7 years) who underwent tracheostoma closure technique between 2001 and 2019 (Table 1). Surgery was indicated for patients in whom closure had not occurred after conservative monitoring for ≥ 2 months following cannula removal. The underlying disease originally requiring tracheostomy was long-term intubation in the intensive care unit (ICU) in 10 cases, malignant tumor surgery in 4, pneumonia in 3, deep neck abscess in 2, acute laryngeal edema in 2, subglottic stenosis in 1, and polyneuritis in 1. Mean duration of tracheostomy patency was 14.0 months (range, 2–43 months). Mean diameter of the patent tracheostoma was 7.17 mm (range, 4–25 mm).

Table 1.

The 23 patients who underwent tracheostoma closure. Patients comprised 12 men and 11 women (mean age, 60.0 SD19.7 years). Surgery was indicated for patients in whom closure had not occurred after conservative monitoring for ≥ 2 months following cannula removal. The underlying disease originally requiring tracheostomy was long-term intubation in the intensive care unit (ICU) in 10 cases, malignant tumor surgery in 4, pneumonia in 3, deep neck abscess in 2, acute laryngeal edema in 2, subglottic stenosis in 1, and polyneuritis in 1. Mean duration of tracheostomy patency was 14.0 months (range, 2–43 months). Mean diameter of the patent tracheostomy was 7.17 mm (range, 4–25 mm)

Case	Sex	Age(years)	Condition requiring tracheostomy	Underlying condtions	Duration of patency (months)	Tracheostomy size (mm)
1	F	36	Long-term ICU	Drug abuse	23	5 × 5
2	M	73	Pneumonia	Diabetes	2	9 × 7
3	M	58	Mediastinitis, Pneumonia	Diabetes	12	4 × 4
4	M	38	Long-term ICU	Polyarterities nodosa	10	8 × 8
5	M	66	Long-term ICU	Diabetes	7	12 × 8
6	F	69	Tongue cancer surgery	None	10	5 × 5
7	F	59	Thyroid cancer surgery	None	13	5 × 5
8	F	82	Long-term ICU	Myasthenia gravis	30	10 × 10
9	M	62	Acute laryngeal edema	Hepatocellular carcinoma	9	4 × 4
10	M	54	Tongue cancer surgery	Hypertension	9	12 × 10
11	F	88	Polyneuritis	None	43	16 × 23
12	F	76	Thyroid cancer surgery	Cardiomegaly	6	7 × 7
13	M	40	Acute laryngeal edema	None	5	5 × 5
14	F	38	Long-term ICU	Diabetes, Hypertension	24	4 × 4
15	F	23	Long-term ICU	None	2	6 × 6
16	M	69	Long-term ICU	Hypertension	23	10 × 10
17	M	82	Deep neck abscess	Hypertension	4	4 × 4
18	M	71	Deep neck abscess	None	5	5 × 5
19	M	91	Long-term ICU	Prostate cancer	11	4 × 4
20	F	80	Aspiration pneumonia	Hypertension	36	4 × 4
21	F	52	Long-term ICU	Hypertension	19	25 × 10
22	F	55	Subglottic stenosis	Rheumatoid arthritis	14	4 × 4
23	M	19	Long-term ICU	None	6	5 × 5

Methods

Surgery was performed under local anesthesia. The surgical procedure is shown in Fig. 1. Two hinge flaps for use in forming the anterior tracheal wall were designed on each side of the tracheostoma, and a cover flap to cover the skin defect was designed on the side of the neck in which the skin was in better condition (Fig. 1a, left). A hinge flap on each side of the tracheostoma was prepared (Fig. 1b). These two hinge flaps were lifted from the sides of the tracheostoma and the skin surfaces were turned inward to form the anterior tracheal wall (Fig. 1c). To prevent air leaking from between the two hinge flaps, multiple layers were sutured together, and a cover flap was created to place over the anterior tracheal wall thus formed (Fig. 1d). The anterior tracheal wall was covered with the cover flap to close the tracheostoma opening (Fig. 1e).

Fig. 1.

Surgical procedure. a Two hinge flaps for use in forming the anterior tracheal wall were designed on each side of the tracheostomy, and a cover flap to cover the skin defect was designed on the left side. b A hinge flap on each side of the tracheostomy was prepared. c These two flaps were lifted from the sides of the tracheostomy and the skin surfaces were turned inward to form the anterior tracheal wall. d To prevent air leaking from between the two hinge flaps, multiple layers were sutured together, and a cover flap was created to place over the anterior tracheal wall thus formed. e The anterior tracheal wall was covered with the cover flap to close the tracheostomy opening

Results

Of the 23 patients, 20 recovered uneventfully after surgery with no complications. Two experienced mild wound infections that improved with antibiotic treatment. One developed subcutaneous emphysema and abscess, which were improved by local lavage, intravenous antibiotic therapy, and wound compression.

Postoperatively, the tracheal lumen was observed via fiberscopy and all cases were regularly followed by CT and fiberscopy at the outpatient department. No stenosis of the tracheal lumen occurred in any patients, and the tracheostomy was successfully closed in all cases.

Discussion

When spontaneous closure of the tracheostoma does not occur, a tracheocutaneous fistula forms and affects quality of life for the patient. The incidence of tracheocutaneous fistula is generally reported as 3.3–29% [1, 2]. Kulber [3] stated that tracheocutaneous fistula forms in 70% of patients for whom tracheostomy has remained patent for > 16 weeks. Nakamura et al. indicated the following reasons for a tracheostomy opening failing to close naturally [4]: pre-tracheostomy issues, such as underlying condition or infection; problems with the surgical method, such as the type of tracheostomy, the size of the tracheostoma opening, or the position of the tracheostomy; post-tracheotomy issues such as long-term patency of the tracheostomy, inappropriate choice of cannula, inappropriate cannula replacement, or granulation; and others, such as coughing and sputum. Higashino et al. [5] also mentioned radiotherapy, multiple tracheostomies, and tracheostomy following total thyroidectomy as reasons for failure of the tracheostoma to close. In that study, the tracheostoma had been patent for > 16 weeks in 7 patients, two of whom had undergone total thyroidectomy. The patients in our study included some who had undergone corticosteroid treatment for connective tissue disease or neuromuscular disease and others with diabetes or deep neck abscess, and all exhibited previously reported risk factors for the failure of the tracheostomy to close naturally.

Methods of tracheostoma closure include: closure by simple suture; closure with a local skin flap; and closure using supporting tissue/hard tissue. Closure by simple suture entails a high risk of mediastinal emphysema, pneumothorax, and wound opening [6, 7], and is not recommended. If a large tracheal wall defect is present, supporting tissue/hard tissue can be used as reconstructive materials, with reported examples including nasal septal cartilage [8], palatal mucosa [9], muscle fascia [10], and muscle flaps [11]. Reconstruction with supportive tissue is not usually required for defects extending across less than one-third of the tracheal wall, and Nakamura et al. recommended the use of hinge flaps to close the defect in the anterior tracheal wall and a cover flap to cover this in the event of the failure of normal tracheostoma closure [4]. This method of closure both minimizes the amount of suturing required and causes almost no complications due to inadequate reconstruction, such as airway stenosis. Although there is scope for debate, this is believed to be because the surface of the skin of the hinge flaps exposed inside the tracheal lumen is ultimately replaced by mucosa-like tissue [12].

The advantages of this procedure include: low invasiveness and reliable closure with few complications; lack of overlap between suture lines of the anterior tracheal wall/hinge flaps and those of the skin defect/cover flap prevents air leaks and opening; absence of stenosis of the tracheal lumen even without the use of hard reconstructive tissue; and feasibility of achieving closure for any size of defect. However, this method has the disadvantage that because neck skin is used, skin flap creation may be difficult in patients who have undergone radiotherapy or cervical surgery, depending on the direction of the incision in the latter case.

In terms of postoperative complications, two patients developed mild wound infections and one exhibited subcutaneous emphysema and abscess. One of these two patients who experienced mild wound infections suffered from poorly controlled diabetes as an underlying condition, and the other had undergone high-dose steroid treatment for polyneuritis and was therefore susceptible to infection. Both patients improved with antibiotic therapy. The patient who developed subcutaneous emphysema and abscess had received treatment for Guillain-Barré syndrome with both high-dose intravenous immunoglobulin therapy and high doses of steroids, and was thus also susceptible to infection. This was improved by local lavage, intravenous antibiotic therapy, and wound compression.

Conclusions

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 for whom the tracheocutaneous fistula has failed to close spontaneously. This method is superior to other methods in that it can be closed without stenosis of the tracheal lumen and that it can be closed even if the size of the tracheocutaneous fistula is large.

Author Contributions

All authors contributed to the design and implementation of the research and to the writing of the manuscript. All authors read and approved the final manuscript.

Funding

None.

Declarations

Conflict of interest

None.

Ethical Approval

This study was conducted with the approval of the Nihon University Itabashi Hospital Ethics Committee (approval number RK-200310–5).