WEBVTT

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*This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.*

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We are seeing an increasing need for creation

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of a permanent tracheal fest administration.

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One indication is laryngeal

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fibrosis which can occur as a result

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of injury,

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infection or irradiation treatment.

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The latter as radiation therapy has

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assumed a greater role in the treatment of laryngeal

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cancer

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treatment.

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For the syndrome of sleep apnea requires a

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permanent tracheostomy.

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Some patients with bilateral vocal cord

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paralysis with aspiration and those

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with chronic obstructive pulmonary disease require a

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permanent tracheal opening.

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Although the long term placement of the tracheostomy

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tube may result in a permanent fest

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administration.

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The time interval is long and

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associated with considerable inconvenience to the

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patient and physician given a

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choice.

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Most patients prefer not to wear or care

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for a tracheostomy appliance.

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The technique of permanent tracheal fest administration will

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be shown graphically and then demonstrated

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surgically.

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The placement of the incisions should be as

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inferior in the neck as possible.

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Allowing finger effusion for speaking

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and the cosmetic advantage of being hidden by a

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shirt or scarf in the

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obese.

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However,

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a more superior placement of the stoma offers

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technical advantages.

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The dimensions for the cervical skin flaps are

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variable but average 2 to 3 centimeters

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horizontally and 1 to 1.5

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centimeters vertically.

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One should allow for approximately 30 to

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40% ultimate narrowing of the stoma.

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The tracheal flaps are created in such a

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fashion that the inferior flap is longer than

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the superior one due to the

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posterior inferior direction

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that the trachea assumes the

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average dimensions of the tracheal flaps are

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1.5 centimeters wide and 1.5

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centimeters long for the inferior flap

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and 1.5 centimeters wide and one

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centimeter long.

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For the superior flap,

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the flaps are then advanced appropriately and

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sewn in place with 40 woven nylon

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suture and removed on the 10th to

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14th,

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post operative day or when healing is

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judged to be sufficient.

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A custom made button can be fashioned for

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sleep apnea patients or those with chronic

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obstructive pulmonary disease that require an

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intermittent tracheostomy

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made from room temperature,

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vulcanizing Silastic.

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The button is created for daytime use to

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seal the stoma.

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It is then removed in the evening or whenever

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necessary for suctioning or ventilation.

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The advantages of the technique of permanent

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tracheal fest administration are that it is a

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quick,

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simple one stage procedure that can

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be performed under local or general

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anesthesia because no skin

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or tracheal tissue is excised.

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This technique has the additional advantage of being

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reversible should conditions change

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allowing tracheostomy closure.

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This patient is 15 years,

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post resection of a cerebellar

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astrocytoma and six years

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post resection of a benign cerebellar

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cyst A tracheostomy had been

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closed several years before with

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resultant upper airway obstruction and

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intermittent aspiration of liquids.

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These laryngeal photos show a right

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vocal chord paralysis and a left

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vocal chord peres.

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The skin incisions are marked and the

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tracheostomy scar will be excised,

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requiring extension of the incisions.

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The skin incisions are made

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and the previous trays are excised.

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The flaps are then elevated in a plane

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superficial to the plasma muscle.

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This patient has a moderate amount of

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subcutaneous fat and thus

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wide undermining is accomplished to

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facilitate advancement of the cervical skin.

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The skin flaps are retracted with 40

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woven nylon sutures as necessary

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excess,

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subcutaneous fat is excised to further

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enhance advancement of the flaps.

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At the conclusion of the procedure,

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fascia in the midline is divided

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using the electric scalpel because in this

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patient,

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considerable scar tissue is encountered from the

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previous tracheostomy.

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The isthmus of the thyroid is mobilized

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superiorly when encountered or more

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commonly excised.

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In this patient,

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it was simply mobilized superiorly.

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The tracheal flap incisions are made with the

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electric scalpel having ensured

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adequate anesthesia of the tracheal

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mucosa care

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should be taken if there is residual vocal

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cord mobility to avoid placing the

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vertical incisions too far laterally

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with resultant recurrent nerve

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damage.

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The tracheal flap is advanced towards the skin

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and sewn in place with 40 woven

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nylon suture.

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The superior tracheal flap is sewn to

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the superior skin incisions

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creating the dimensions for the ultimate vertical

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length of the permanent trachea stone.

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The skin flap is sewn to the tracheal

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mucosa

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and the flap is advanced into position

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as this is accomplished.

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The final tracheostoma begins to take

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form

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when performed under local anesthesia.

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Tracheal mucosal anesthesia is

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necessary to inhibit reflex coughing.

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The advantages of minimal blood loss

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and absence of an obstructive endotracheal

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tube make local anesthesia

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preferable.

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The sutures are left long and

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shortened at the termination of the procedure.

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In order to prevent suture tags from

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obstructing the closure.

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A bland ointment is applied in order to prevent

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crusting and to retract the sutures

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away from the tracheal mucosa,

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digital closure of the stoma is performed at

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the conclusion of surgery to reassure the

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patient that vocal function is intact.

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12,

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three,

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our patient is now six months

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postoperative and enjoyed an uneventful

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recovery.

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Cora,

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could you tell us what kind of difficulties did you have before your

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surgery?

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Some,

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uh,

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I would get tired fast

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walking up the stairs or those

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kind of start breathing.

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Did you have trouble swallowing before your surgery?

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Yes,

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I did.

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What kind of trouble did you have?

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I would start coughing and I

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would have to stop eating because,

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uh,

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I would cough a lot.

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And what kind of problems have you had since your surgery?

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Well,

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now I do all sorts of things.

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I don't get tired like I used to.

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And how about trouble breathing?

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No,

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I haven't.

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Are you able to climb stairs.

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Now,

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I see socially.

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Were you incapacitated before you had your

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operation?

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Uh,

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yes.

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So I didn't want,

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I didn't like nobody to listen at me because I

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was pretty tired and I would be

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embarrassed.

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And how about,

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since surgery?

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Well,

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since my surgery,

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I don't really care that

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they look at me because I,

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well,

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I've been doing pretty good and I don't really

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care if they dare me because I cover my

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throat.

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I see.

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Do you have any,

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do you go to parties now?

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Whereas before you did not?

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No,

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I do before.

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I didn't go.

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Could we take a look at your stoma?

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Yes.

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Now take a deep breath in for us.

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Blow it out,

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deep breath again.

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Blow it out.

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Now,

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count to three,

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12,

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three.

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The next patient is an attorney who developed

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progressive laryngeal fibrosis and edema

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for 6.5 years after high dose

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radiation for an extensive laryngeal

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cancer.

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These laryngeal photos show an

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immobile larynx with an inadequate airway.

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This patient is now over a year post

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operative and healed uneventfully despite his high

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dose of irradiation,

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Ralph,

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can you tell us what kind of problems you had before your surgery?

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I had a lot of difficulty in breathing,

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um,

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especially if I try to walk fast or

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climb stairs.

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And about 18 months ago,

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it got worse than that.

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It got to the point where occasionally I was feeling like I was gonna

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black out.

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Uh,

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my voice was

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about one half the strength it is now,

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give that much and I

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couldn't,

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uh,

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project my voice at all.

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So I found it difficult to do my work

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and eventually the swelling

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became so bad that

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I'd have trouble breathing while

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driving.

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And on a couple of occasions nearly blacked out in a freeway

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which,

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uh,

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sent me to you.

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What kind of problems have you had since your surgery?

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Well,

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the problems have decreased considerably.

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I've gotten off pregnizone

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lost about £30.

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I can breathe again.

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Um,

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I do have a problem with mucus.

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The more I talk toward the end of the day I get more and more

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collection of mucus.

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Hi.

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Don't think I could run a

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marathon but,

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uh,

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I can run again,

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which I couldn't before in your work as an

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attorney.

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How do you function in court?

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Uh,

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primarily my work is limited now to

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managing,

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uh,

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attorneys and other claims people.

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And,

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uh,

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but that requires a lot of public speaking and,

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uh,

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similar work to courtroom work.

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And,

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uh,

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I manage well,

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as long as I have a microphone in a big crowd,

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Ralph,

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we'd like to take a look at your stone.

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If we could please

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take a deep breath in for me,

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blow it out,

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deep breath in.

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Bought out.

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Now,

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would you say 123 for me?

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123?

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I want to ask one more question.

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Are you able to whistle at pretty girls.

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No.