We are seeing an increasing need for creation
of a permanent tracheal fest administration.
One indication is laryngeal
fibrosis which can occur as a result
of injury,
infection or irradiation treatment.
The latter as radiation therapy has
assumed a greater role in the treatment of laryngeal
cancer
treatment.
For the syndrome of sleep apnea requires a
permanent tracheostomy.
Some patients with bilateral vocal cord
paralysis with aspiration and those
with chronic obstructive pulmonary disease require a
permanent tracheal opening.
Although the long term placement of the tracheostomy
tube may result in a permanent fest
administration.
The time interval is long and
associated with considerable inconvenience to the
patient and physician given a
choice.
Most patients prefer not to wear or care
for a tracheostomy appliance.
The technique of permanent tracheal fest administration will
be shown graphically and then demonstrated
surgically.
The placement of the incisions should be as
inferior in the neck as possible.
Allowing finger effusion for speaking
and the cosmetic advantage of being hidden by a
shirt or scarf in the
obese.
However,
a more superior placement of the stoma offers
technical advantages.
The dimensions for the cervical skin flaps are
variable but average 2 to 3 centimeters
horizontally and 1 to 1.5
centimeters vertically.
One should allow for approximately 30 to
40% ultimate narrowing of the stoma.
The tracheal flaps are created in such a
fashion that the inferior flap is longer than
the superior one due to the
posterior inferior direction
that the trachea assumes the
average dimensions of the tracheal flaps are
1.5 centimeters wide and 1.5
centimeters long for the inferior flap
and 1.5 centimeters wide and one
centimeter long.
For the superior flap,
the flaps are then advanced appropriately and
sewn in place with 40 woven nylon
suture and removed on the 10th to
14th,
post operative day or when healing is
judged to be sufficient.
A custom made button can be fashioned for
sleep apnea patients or those with chronic
obstructive pulmonary disease that require an
intermittent tracheostomy
made from room temperature,
vulcanizing Silastic.
The button is created for daytime use to
seal the stoma.
It is then removed in the evening or whenever
necessary for suctioning or ventilation.
The advantages of the technique of permanent
tracheal fest administration are that it is a
quick,
simple one stage procedure that can
be performed under local or general
anesthesia because no skin
or tracheal tissue is excised.
This technique has the additional advantage of being
reversible should conditions change
allowing tracheostomy closure.
This patient is 15 years,
post resection of a cerebellar
astrocytoma and six years
post resection of a benign cerebellar
cyst A tracheostomy had been
closed several years before with
resultant upper airway obstruction and
intermittent aspiration of liquids.
These laryngeal photos show a right
vocal chord paralysis and a left
vocal chord peres.
The skin incisions are marked and the
tracheostomy scar will be excised,
requiring extension of the incisions.
The skin incisions are made
and the previous trays are excised.
The flaps are then elevated in a plane
superficial to the plasma muscle.
This patient has a moderate amount of
subcutaneous fat and thus
wide undermining is accomplished to
facilitate advancement of the cervical skin.
The skin flaps are retracted with 40
woven nylon sutures as necessary
excess,
subcutaneous fat is excised to further
enhance advancement of the flaps.
At the conclusion of the procedure,
fascia in the midline is divided
using the electric scalpel because in this
patient,
considerable scar tissue is encountered from the
previous tracheostomy.
The isthmus of the thyroid is mobilized
superiorly when encountered or more
commonly excised.
In this patient,
it was simply mobilized superiorly.
The tracheal flap incisions are made with the
electric scalpel having ensured
adequate anesthesia of the tracheal
mucosa care
should be taken if there is residual vocal
cord mobility to avoid placing the
vertical incisions too far laterally
with resultant recurrent nerve
damage.
The tracheal flap is advanced towards the skin
and sewn in place with 40 woven
nylon suture.
The superior tracheal flap is sewn to
the superior skin incisions
creating the dimensions for the ultimate vertical
length of the permanent trachea stone.
The skin flap is sewn to the tracheal
mucosa
and the flap is advanced into position
as this is accomplished.
The final tracheostoma begins to take
form
when performed under local anesthesia.
Tracheal mucosal anesthesia is
necessary to inhibit reflex coughing.
The advantages of minimal blood loss
and absence of an obstructive endotracheal
tube make local anesthesia
preferable.
The sutures are left long and
shortened at the termination of the procedure.
In order to prevent suture tags from
obstructing the closure.
A bland ointment is applied in order to prevent
crusting and to retract the sutures
away from the tracheal mucosa,
digital closure of the stoma is performed at
the conclusion of surgery to reassure the
patient that vocal function is intact.
12,
three,
our patient is now six months
postoperative and enjoyed an uneventful
recovery.
Cora,
could you tell us what kind of difficulties did you have before your
surgery?
Some,
uh,
I would get tired fast
walking up the stairs or those
kind of start breathing.
Did you have trouble swallowing before your surgery?
Yes,
I did.
What kind of trouble did you have?
I would start coughing and I
would have to stop eating because,
uh,
I would cough a lot.
And what kind of problems have you had since your surgery?
Well,
now I do all sorts of things.
I don't get tired like I used to.
And how about trouble breathing?
No,
I haven't.
Are you able to climb stairs.
Now,
I see socially.
Were you incapacitated before you had your
operation?
Uh,
yes.
So I didn't want,
I didn't like nobody to listen at me because I
was pretty tired and I would be
embarrassed.
And how about,
since surgery?
Well,
since my surgery,
I don't really care that
they look at me because I,
well,
I've been doing pretty good and I don't really
care if they dare me because I cover my
throat.
I see.
Do you have any,
do you go to parties now?
Whereas before you did not?
No,
I do before.
I didn't go.
Could we take a look at your stoma?
Yes.
Now take a deep breath in for us.
Blow it out,
deep breath again.
Blow it out.
Now,
count to three,
12,
three.
The next patient is an attorney who developed
progressive laryngeal fibrosis and edema
for 6.5 years after high dose
radiation for an extensive laryngeal
cancer.
These laryngeal photos show an
immobile larynx with an inadequate airway.
This patient is now over a year post
operative and healed uneventfully despite his high
dose of irradiation,
Ralph,
can you tell us what kind of problems you had before your surgery?
I had a lot of difficulty in breathing,
um,
especially if I try to walk fast or
climb stairs.
And about 18 months ago,
it got worse than that.
It got to the point where occasionally I was feeling like I was gonna
black out.
Uh,
my voice was
about one half the strength it is now,
give that much and I
couldn't,
uh,
project my voice at all.
So I found it difficult to do my work
and eventually the swelling
became so bad that
I'd have trouble breathing while
driving.
And on a couple of occasions nearly blacked out in a freeway
which,
uh,
sent me to you.
What kind of problems have you had since your surgery?
Well,
the problems have decreased considerably.
I've gotten off pregnizone
lost about £30.
I can breathe again.
Um,
I do have a problem with mucus.
The more I talk toward the end of the day I get more and more
collection of mucus.
Hi.
Don't think I could run a
marathon but,
uh,
I can run again,
which I couldn't before in your work as an
attorney.
How do you function in court?
Uh,
primarily my work is limited now to
managing,
uh,
attorneys and other claims people.
And,
uh,
but that requires a lot of public speaking and,
uh,
similar work to courtroom work.
And,
uh,
I manage well,
as long as I have a microphone in a big crowd,
Ralph,
we'd like to take a look at your stone.
If we could please
take a deep breath in for me,
blow it out,
deep breath in.
Bought out.
Now,
would you say 123 for me?
123?
I want to ask one more question.
Are you able to whistle at pretty girls.
No.