Redo Tracheostomy: Our Experience, Problems Encountered and How to Overcome Them

Abstract

Tracheostomy is a life-saving procedure done electively or most commonly in emergency basis. In patients with diagnosed case of cancer in upper airway tract they usually require tracheostomy at some point of time during their whole treatment procedure. Patients receiving radiotherapy or chemotherapy or combination of these are at high risk of developing post treatment changes in neck anatomy. Redo tracheostomy due to any reasons in such types of patients is a surgical challenge. The purpose of this article is to share our surgical technique in redo tracheostomy. During a period of two years 39 patients with diagnosed cancer in head neck region underwent redo tracheostomy at the hand of the author. Twenty-six patients were had received chemoradiation for their primary cancer and 6 patients were planned for second surgery due to recurrence disease in oral cavity. Reasons for redo tracheostomy are: sixteen patients were post chemoradiation on follow up with accidental expulsion of tube, 17 patients were recurrence/residual disease and 6 patients were plan for second surgery due to recurrence disease. In 9 cases the surgery was started by other doctor and taken over by the author due to profuse bleeding (5 cases) and failure to localised the trachea (4 cases). Among the 39 patients successful redo tracheostomy was possible in all. Mild surgical emphysema was encountered in 3 patients which was not significant. There was no other complication related to tracheostomy till the patients were discharge from the hospital. When redo tracheostomy is required in a post chemoradiation patients maintaining the proper dissection plane and procedure is important to avoid unnecessary complication intraoperatively.

Introduction

Cancers are generally considered as disease of the developed countries. Worldwide the incidence of cancer is 350–500/100,000 while in India it is 100/100,000, much lower as compare globally [1]. Head and neck cancers are the 6th most common cancer worldwide. According to population based cancer registries these constitute the commonest cancer in men and third most common cancer in women in India [2]. This high incidence is attributed to the widespread consumption of tobacco in any form-smoked, chewed, applied locally on the gum and inhaled. According to the Global Adult Tobacco Survey, [3] the consumption of tobacco among adult in India is 34.6%.

Of the head and Neck cancers, oral cancers are the commonest and constitute 40–70% [1]. Around 40,000 cases of pharyngeal cancers, excluding nasopharyngeal cancer, and nearly 29,000 cases of laryngeal cancers occur in India every year [4]. In North East India pharyngeal cancer is relatively high. One study showed that in Dibrugarh, Assam, hypopharyngeal cancers are the major cancers among male population [5]. Majority of these cancer patients in India are presenting late to hospital. In a survey conducted amongst patients with advanced cancer presenting to a tertiary cancer center in India, majority delayed the decision to seek medical attention despite observing abnormal lesion in their mouth. [6] In ability to seek timely medical attention is one of the main factors contributing to approximately 60% of cases presenting in an advanced stage (Stage III, IV) [7, 8]. Patients with tumour in airway track when presenting at late stage to hospital are more prone to present with compromised airway. These patients required tracheostomy either on emergency basis or electively before starting treatment. This airway obstruction may be in upper airway (above the mid trachea) or in lower airway (below the mid trachea). Recognising the site of obstruction has implication in management as upper airway obstruction can be bypassed by tracheostomy while the lower airway obstruction may not be [9].

Locally advanced head and neck cancers including pharyngeal cancers are generally treated with radiation or chemotherapy or combination chemoradiation [10, 11]. After chemoradiation the laryngopharynx may remain structurally intact but functionally they may remain incompetent, resulting in chronic aspiration, persistent bulky edema, fibrosis and hypomobility causing airway obstruction thereby rendering the patient to be tracheostomy dependent. In this article we try to summarize the number of tracheostomised patients with diagnosed cancer in head and neck region treated in our hospital, and those who required redo tracheostomy due to any reason which will be mentioned later. The primary objective is to identify the number of redo tracheostomy, causes associated with and surgical problems encountered during the procedure. Redo tracheostomy is a topic which is less discussed in literature. In this article we try to elaborate the surgical problems encountered and how to overcome them from our experience.

Materials and methods

Materials

Between January 2015 and December 2017, overall 543 patients underwent tracheostomy in our institution (Table 1). All these patients are diagnosed case of malignant tumor in head neck region treated at Dr. B. Borooah Cancer Institute, Guwahati, Assam, India. Tracheostomy was done either on emergency or elective basis. This study mainly focus on those patients who underwent redo tracheostomy. The surgical techniques described below are the techniques we routinely perform in any redo tracheostomy. In these 24 months duration 39 patients underwent redo tracheostomy.

Table 1.

Distribution of tracheostomised patients according to their diagnosed disease

Total number of tracheostomised patients	Diagnosed disease	Number of tracheostomised patients	Number of redo tracheostomy
543	Ca Nasopharynx	23	Nil
	Ca Oropharynx	132	7
	Ca Larynx	224	12
	Ca Hypopharynx	127	14
	Anaplastic Ca Thyroid	5	Nil
	Lymphoma	6	Nil
	Pre operative	23	6
	Mediastinal mass with b/l VC palsy	3	Nil

The reasons for redo tracheostomy are (Table 2):

1. In 16 patients accidental expulsion of tracheostomy tube during follow up period after receiving treatment (radiation/chemotherapy) for their disease.

2. In 17 patients due to recurrent/residual growth

3. In 6 patients second surgery was planned due to recurrent disease in oral cavity

Table 2.

Distribution of redo tracheostomy along with their cause

Total number of redo tracheostomy	Diagnosed disease	Number of redo tracheostomy	Reasons for redo tracheostomy
39	Ca Oropharynx	7	4 patients: due to recurrent/residual growth 3 patients: accidental expulsion (on follow up post RT/CT)
	Ca Larynx	12	7 patients: due to recurrent/residual growth 5 patients: accidental expulsion (on follow up post RT/CT)
	Ca Hypopharynx	14	6 patients: due to recurrent/residual growth 8 patients: accidental expulsion (on follow up post RT/CT)
	Pre operative	6	Planed for second surgery with free flap reconstruction due to recurrent disease

Methods

All these patients who required redo tracheostomy presented to our hospital with some form of difficulty breathing except those six patients planed for surgery. All of them received primary treatment in our hospital and location of primary disease could be identified immediately based on previous records. Twenty-six patients presented to OPD for which quick assessment were done by rigid endoscope and sent immediately to operation theatre. Thirteen patients present directly in emergency department with breathing difficulty and sent to minor operation theatre.

All these redo tracheostomy was performed in minor operation theatre. Preparation was done as routine surgical procedure maintaining the aseptic condition. In 6 patients supine position with elevated shoulder with a sandbag was possible, in 29 patients supine position without sandbag and 4 patients in sitting position. Local infiltration was given with 2% xylocaine with adrenaline in 32 patients and the other 7 patients infiltration was not given due to severe respiratory distress and tracheostomy was performed in a very limited time. In five patients they have thin neck who had received chemoradiation for their primary disease and presented with recurrence disease and severe difficulty breathing. A single straight incision was given at the previous scar in the midline. The incision was then opened with artery forcep for temporary relieve of the patients. The stoma was then enlarged by removing the fibrosed tissue around the previous tracheal stoma. Two patients in sitting position single stab incision was given as described above. Both the patients had thin neck. In other patients they were not relatively in severe breathing difficulty. They were made to lie down in supine position. Incision was extended few millimetres above and below the previous tracheostomy site in the midline. In our experience a small dimpling is usually seen at the corresponding closed tracheal stoma. The incision was given above and below this dimpling. The skin and subcutaneous tissue flap is then elevated without much extension laterally. The dissection is limited around the dimpling area and the fibrosed dimpling tissue on top of tracheal stoma can easily be removed after dissection. In 9 patients (post chemoradiation) the procedure was started by a junior doctor. Excessive bleeding was encountered in 5 patients and failure to locate the trachea in 4 patients and the surgery was taken over by a senior doctor and redo tracheostomy was done successfully. After operation 5 patients in whom excessive bleeding was encountered were kept in ICU overnight for observation and the other patients were kept in ward and discharge subsequently.

Result

Following our surgical technique redo tracheostomy was successfully done in all 39 patients. In three patients the surgery was started by a junior doctor, excessive bleeding was encountered and the surgery was taken over by a senior surgeon and successful redo tracheostomy was done. Postoperatively 3 patients had surgical emphysema which was not significant and subside subsequently. No secondary bleeding or any complications related to tracheostomy was encountered till the patients were discharged from the hospital.

Discussion

With the introduction of chemoradiation, pharyngeal carcinoma are preferably treated by this modality with the aim of organ preservation as studies have shown that concurrent chemotherapy and radiation achieved outcome equivalent to surgery while sparing over 70% of patients from laryngectomy [12, 13]. However concurrent chemoradiation is associated with acute toxicity which may cause persistence bulky edema, fibrosis, hypomobility thereby rendering the patients tracheostomy dependent [14]. When such tracheostomy dependent patients encounter accidental expulsion of tracheostomy tube during their follow up period, reinsertion may not be easy, more so in countries where trained medical personnel are not easily available. These patients usually presented to hospital with respiratory distress with closed tracheal stoma and redo tracheostomy is always a challenge. Edema, inflammation, increased vascularity in the radiated field are seen during the course or within three months of radiation therapy [15]. Surgical intervention in such field put at high chance of profuse bleeding as it happen in 5 of our cases which was later taken over by a senior surgeon. Thickening of skin and platysma, stranding of subcutaneous tissue are changes seen after radiation [13]. These changes contribute significantly to difficulty in locating the trachea (as it happen in 4 cases) and unnecessary exploration may end up in unwanted bleeding and wasting of time. Though different difficult tracheostomy had been explained in the text [15] but most of these tracheostomy were performed under general anaesthesia where ample time and precaution can be taken. In our situation all these procedures were performed in emergency basis without general anesthesia where the margin of safety is very narrow.

In a routine tracheostomy procedure the shoulder of the patient is elevated and the head is extended [16]. This position elevate the larynx and expose the upper trachea more anteriorly and identifying and creating a stoma in the trachea become more safe and easy during tracheostomy. But in post radiation scenario due to osteoradionecrosis of the bone and cartilaginous structures extending the neck may cause more harm to the patient. In our cases in 6 patients elevating the shoulder with sandbag was possible, in 29 patients this was not possible due to exaggerated airway compromise and the patient could not maintain that position so tracheostomy has to be done without elevating the shoulder. In 4 patients neither supine nor elevated shoulder position was possible due to flexed position of neck post chemoradiation fibrosis. In these patients tracheostomy was done in sitting position but following our surgical principles redo tracheostomy was possible in all these patients with different position.

Conclusion

From our experience we concluded that redo tracheostomy, especially in post chemoradiation patients, should be done by an experience surgeon. Anatomical changes in the previous tracheostomised site in neck should be expected and surgical dissection should be done cautiously to prevent unnecessary bleeding.

Compliance with Ethical Standard

Conflict of interest

The author declare that they have no conflict of interest.

Informed Consent

Informed consent was taken from all the participants included in the study.