Pediatric Otolaryngology:
Principles and Practice
Pediatric Tracheotomy: A Review of Technique ANDREW J. HOTALING, MD, WAYNE K. ROBBINS, DO, DAVID N. MADGY, DO, WALTER M. BELENKY, MD
It is well documented that the morbidity, mortality, and complication rates for pediatric tracheotomy are significantly higher than for adult tracheotomy. IF4 With trends toward performing pediatric tracheotomies in an increasingly premature population with less emergent indications, it is essential that techniques be reviewed for any factors that may reduce complications. At Children’s Hospital of Michigan, the same tracheotomy technique has been used since 1985. The technique and experience with 141 patients are reviewed. REVIEW OF THE LITERATURE Postoperative complications from tracheotomy are divided into early and late complications. The most frequently described early complications are accidental decannulations, plugging or cannular obstruction, pneumothorax, and postoperative bleeding.‘-3*5*6 Accidental decannulation is of particular concern as there are several reports of pneumothorax, pneumomediastinum, and even cardiac arrest with attempts at emergent recannulausually detion. 2-4,6-8 Late complications, scribed as occurring after the seventh postoperative day, may also be influenced by operative technique. Accidental decannulation and
From the Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, IL; Department of Otolarynology, Children’s Hospital of Michigan, Detroit, MI; and the Flint Osteopathic Hospital, Flint, MI. Presented at SENTAC, held in Washington, DC, December 9, 1990. Address reprint requests to Andrew J. Hotaling, MD, Loyola University Medical Center, 2160 S First Ave, Maywood, IL 60153. Copyright 0 1992 by W.B. Saunders Company 0196-0709/92/l 302-0009$5.00/O American
Journal
of Otolaryngology,
plugging are frequently noted. Stoma1 granulation, skin erosion, and tracheocutaneous fistula are also observed. Although there are numerous articles that review operative technique, there is no clear consensus on a number of technical aspects. The most controversial issue is the tracheal incision. The options include vertical incision, horizontal incision, inferiorly based flap as described by Bjork, and excision of the anterior tracheal wall.’ Kirchner et al report that excision of the anterior tracheal wall results in tracheal stenosis in the pediatric age group. 7*10 This finding is supported by Tepas et al who noted an increased number of decannulations and tracheal obstruction by granulation tissue, occurring at a mean of 4 days postoperatively using this technique.” Although the vertical incision is most frequently used in children, it is reported by one author to be associated with tracheal stenosis.l Depending on the diameter of the tracheal lumen, the horizontal incision may make cannulation difficult although it is associated with a low degree of stenosis. There is little written about the use of the inferiorly based flap in children although it is frequently used in adults. Although the articles reviewed state that the risk of stenosis is low, follow-up data is lacking.2.12,13 Cosmetically, the direction of the skin incision makes little difference, as reflected by an equal number of proponents for both horizontal and vertical skin incisions. Kirchner argues strongly in favor of the vertical skin incision, stating that “with the horizontal skin incision, the redundant tissue above the incision tends to rest on the shaft of the cannula and to displace its distal end posteriorly.7” He states that the horizontal incision may cause
Vol 13, No 2 (March-April),
1992: pp 115-l 19
115
116
HOTALING
obstruction and mucosal irritation, whereas the vertical incision allows for free movement of the cannula with respiration and deglutition. Management of the thyroid isthmus has also caused a divergence in operative technique. The majority of authors recommend dividing the isthmus only when necessary, otherwise retracting it superiorly or inferiorly to make the tracheal incision. There are a number of authors who recommend division of the isthmus routinely. The stated reasons for routine division are varied but include better visualization of the trachea in the event of accidental decannulation, elimination of constant pressure on the inferior aspect of the cannula displacing the tip anteriorly, and improved control of postoperative bleeding.6*7 One author reports marked interstitial hemorrhage noted in a thyroid gland at the autopsy of a child with significant postoperative bleeding.ll The use of stay sutures lateral to the tracheal incision for the first postoperative week is almost unanimously supported in the literature. One 15-year review by Line et al raises concern, however, that these stay sutures may have contributed to tracheomalacia and flap stenosis in at least two patients.14 For this reason, the authors stopped using stay sutures in the trachea and began suturing the flange of the tube to the skin. In reviewing complications, these authors noted an increase in accidental decannulations during the period when the stay sutures were not used. OPERATIVE
ET AL
platysma are sharply incised in the midline, exposing the subcutaneous fat, which is then excised to expose the anterior cervical fascia. Careful hemostasis is obtained. Frequent digital palpation of the trachea is essential and is performed after each adjustment of retraction. With the midline identified, dissection is performed between the strap muscles to the thyroid isthmus, which is either mobilized superiorly or inferiorly or is divided by suture ligature. The pretracheal fascia is then bluntly dissected from the anterior trachea. After the cricoid is positively identified by palpation and inspection, a trach hook is placed between the cricoid and the first tracheal ring to elevate and stabilize the trachea. A no.-15 blade scalpel is used to incise the trachea horizontally below the second or third tracheal ring. The incision is carried inferiorly at the 2to 3-o’clock and 9- to lo-o’clock positions of the third or fourth tracheal ring using scissors to fit the diameter of the planned tracheostomy tube. Electrocautery is used to obtain hemostasis of the tracheal incisions. This maneuver creates an inferiorly based flap in the anterior tracheal wall. This flap is then sewn bilaterally to the subcutaneous tissue at the inferior margins of the incision using absorbable suture [Fig 1).The stoma created is more secure and less dependent on the tracheotomy tube for patency. Nonabsorbable sutures are placed bilaterally through the cut tracheal ring to serve as traction sutures for the first 3 to 5 postoperative days. Each suture is tied
TECHNIQUE
At Children’s Hospital of Michigan, the same technique for pediatric tracheotomy has been used since 1985. When the decision to perform a tracheotomy is made, the tracheotomy nurse is consulted to begin parental and/ or primary caregiver teaching. All tracheotomies are performed in the operating room under general endotracheal anesthesia. Hyperextension of the neck is achieved with a shoulder roll and maintained by taping the mandible to the head of the table. The skin is injected in a vertical fashion from the cricoid ring inferiorly using 0.5% xylocaine with I:~OO,OOO epinephrine. The skin and
Fig 1. Inferior-bared trap-door tracheotomy incision secured to subcutaneous tissue inferiorly with absorbable suture. Trach hook under cricoid is stabilizing the trachea.
PEDIATRIC
117
TRACHEOTOMY
twice. The first series of knots is placed just anterior to the skin. The second series is placed 4 to 6 cm lateral to the first series. The procedure of placing the tracheotomy tube is rehearsed with the anesthesiologist so that it is understood that the endotracheal tube will be withdrawn superiorly only until it is just above the stoma. The endotracheal tube can then be easily repositioned if there is difficulty with ventilation via the tracheostomy tube. An appropriately sized tracheostomy tube is inserted, and connection is made to the ventilation system. Until the ties are secure, the tracheostomy tube is held in position by a member of the surgical team. Bilateral auscultation of the chest is performed. When adequate ventilation is verified, the tracheostomy tube is then tied in position. The tying is performed by flexing the neck and tying securely so that one finger can be placed under the tie with the neck flexed. The trach hook is then removed. After tying, auscultation is repeated to ensure adequate ventilation. When ventilation is adequate, the endotracheal tube is then removed. Two 1%in to Z-in pieces of l-in cloth adhesive tape are then marked “left do not remove” and “right do not remove.” Each marked piece is placed between the two strands of each stay suture between the two sets of knots to secure the traction sutures to the chest. In the immediate postoperative period, the child is transferred to the intensive care unit (ICU). The child is accompanied from the operating room to the ICU by a member of the surgical team. A stat portable chest x-ray is obtained and reviewed for placement of the cannula, pneumothorax, and pneumomediastinum. The patient is suctioned as needed. The surgical team member reviews the recannulation procedure and the use of traction sutures with the ICU nursing staff. If stable and without other significant problems, the patient can be transferred to a regular floor on the first postoperative day. Suctioning equipment, a spare trach set, the inserting cannula for the tracheotomy tube in use, and humidification are kept at the bedside at all times. The patient may be maintained on an apneaibrachycardia monitor and pulse oximetry as indicated. Discharge planning is initiated in the early postoperative period. The child is monitored closely by the surgical staff
postoperatively. The initial tracheostomy tube change is made by two members of the surgical team on the fifth to seventh postoperative day. DISCUSSION
Several 5- and lo-year reviews of experience with pediatric tracheotomies have documented changing trends.‘-3+5983”.14 Most consistently noted are the changing indications for tracheotomy. In the past, tracheotomy was indicated in the management of inflammatory diseases; currently, these diseases are better managed by endotracheal intubation in an ICU setting in most hospitals. The advent of neonatology and improvement in technology has provided a younger population of patients with tracheotomies.3 Many of these neonates require prolonged intubation due to their prematurity. The more recent advances by surgical subspecialities to correct congenital anomalies of craniofacial, neurosurgical, and cardiac origins account for an increasing percentage of tracheotomies today. With these changes toward more elective indications for tracheostomy, it is essential that complications be minimized by any technical advantage. The use of the inferior-based flap sutured to the subcutaneous tissue provides a secure stoma less dependent on the cannula to maintain patency. This flap decreases the risk of accidental decannulation, the most frequent postoperative complication in most series. Pneumothorax and pneumomediastinum are also frequently associated with emergent attempts at recannulation. These complications can also be limited by use of the inferior-based flap. In the series of 141 pediatric tracheotomies, there have been no documented accidental decannulations, supporting the belief that the inferior-based flap maintains the patency of the stoma during the immediate postoperative period. If required, the lateral stay sutures would facilitate recannulation. The concern has been raised that the Bjork flap may result in a higher incidence of tracheal stenosis in children. However, several animal studies suggest that the inferior-based flap is associated with the lowest incidence of stenosis.l”,15 Lulenski and Batsakis compared
118
vertical and inferior based flap incisions in dogs and found no difference between controls and the inferior-based flap incisions, compared with the vertical incisions that resulted in an 18% decrease in cross-sectional area.l’ These authors suggested that with the vertical incision the tracheostomy tube caused pressure against the cut edges of the cartilaginous rings. The pressure resulted in inhibition of the normal healing process, as demonstrated microscopically by the lack of an inflammatory response. In the literature reviewed, there is no evidence that the inferiorbased flap increases the incidence of tracheal stenosis. At Children’s Hospital of Michigan there have been 5 patients with tracheal stenosis and 15 patients with suprastomal anterior tracheal wall collapse. Of the 5 patients noted to have tracheal stenosis, 3 have been decannulated and required no further treatment. Two of the 5 patients remain with tracheotomies. In the series of 15 patients noted with suprastomal collapse of the anterior tracheal wall, 9 have been decannulated without difficulty or further treatment. Six of the patients remain with tracheotomies. Of note, 1 of these patients, a neonate was found to have an anterior neck perithyroid abscess that was discovered at the time of tracheotomy. The anterior tracheal collapse in this patient may have been the result of this pre-excising abscess. It is thought that there may be an increased rate of tracheocutaneous fistula, which is addressed preoperatively with the parents. Twenty-three percent of the decannulated patients had a tracheocutaneous fistula that required closure. The elective closure of a tracheocutaneous fistula is preferable to major morbidity or even mortality from accidental decannulation. Other series report tracheocutaneous fistula rates of 13% to 35%.29'6 Although the choices of skin incisions probably have little significance in reducing postoperative complications, the vertical incision has some merit. As noted in the literature, the vertical incision allows for movement of the tracheotomy tube and may decrease displacement of the tip of the cannula into the posterior tracheal wall, limiting granulation tissue and possibly eliminating one source of tubal obstruction. As noted earlier, a horizontal skin incision may cause a reundancy of tissue
HOTALING
ET AL
below the incision, which tends to increase the distance between the skin and the tracheal incisions. This redundant tissue may make recannulation more difficult, especially in an emergent situation. More practically, however, the vertical incision is easily extended if required. Routine division of the thyroid isthmus has theoretical advantages. Although division is not routine in this technique, division of the isthmus is performed when necessary. The incidence of postoperative bleeding associated with the thyroid gland is very small by reports in the literature. Without strong evidence in favor of division, this point is best left to clinical judgement rather than ritualistic procedure. Finally, postoperative bleeding is always a concern in tracheotomy. Removing the subcutaneous fat may be a factor in decreasing postoperative bleeding. Further, removal of this tissue allows for better visualization of the trachea, both at the time of surgery and in the event of accidental decannulation. CONCLUSION
With the complication rate of 20% to 49% and mortality of 2% to 8.5% associated with pediatric tracheotomies, technical aspects must be examined closely.2~3*“*‘4~16 Having reviewed the literature and the experience at Children’s Hospital of Michigan, there are several aspects of this surgical technique that are effective in minimizing postoperative complications. Most significant is the use of the inferior-based tracheal flap to create a more secure stoma. Resection of the subcutaneous fat has also limited postoperative oozing and improved visualization of the trachea for cannulation. In 141 tracheotomies performed since 1985, there have been no documented accidental decannulations. This technique appears to be safe and effective in limiting complications. REFERENCES 1. Crysdale WS, Feldman RI, Naito K: Tracheotomies: A lo-year experience in 319 children. Ann Otol Rhino1 Laryngol 94:439-443, 1988 2. Gilmore BB, Mickelson SA: Pediatric tracheotomy:
PEDIATRIC
TRACHEOTOMY
Controversies in management. Otolaryngol Clin North Am 19:141-151, 1986 3. Kenna MA, Reilly JS, Stool SE: Tracheotomy in the preterm infant. Ann Otol Rhino1 Laryngof 96:68-71, 1987 4. Tepas JJ: Tracheostomy in infants and children. Ear Nose Throat J 62484-488, 1983 5. Carter P, Benjamin B: Ten-year review of pediatric tracheotomy. Ann Otol Rhino1 Laryngol92:398-400, 1983 6. Gerson CR, Tucker GF: Infant tracheotomy. Ann Otol Rhino1 Laryngol 91:413-416, 1982 7. Kirchner JA: Avoiding problems in tracheotomy. Laryngoscope 96:55-57, 1986 8. Stool SE, Eavey RD: Tracheotomy, in Bluestone CC, Stool SE, Scheetz MD (eds): Pediatric Otolaryngology (ed 2) Philadelphia, PA, Saunders, 1990, pp 1226-1243 9. Bjork VO: Partial resection of the only remaining lung with aid of respirator treatment. J Thorac Cardiovasc Surg 39:179-188, 1960 10. Arola MK, Inberg MV, Puhakka, H: Tracheal steno-
119
sis after tracheostomy and arter orotracheal cuffed intubation. Acta Chir S&d 147:183-192, 1981 11. Tepas JJ, Heroy JH, Shermeta DW, et al: Tracheostomy in neonates and small infants: Problems and pitfalls. Surgery 89:635-639, 1981 12. Lulenski GC. Batsakis JG: Tracheal incision as a contributing factor to trachea{ stenosis. Ann Otolaryngol 84:781-786, 1975 13. Price DG: Techniques of tracheostomy for intensive care unit patients. Anesthesia 38:902-904, 1983 14. Line WS, Hawkins DB, Kahlstrom EJ, et al: Tracheotomy in infants and young children: The changing perspective 1970-1985. Laryngoscope 96:510-515, 1986 15. Mendez-Picon G, Ehrlich FE, Salzberg AM: The effect of tracheostomy incisions on tracheal growth. J Pediatr Surg 5:681-684, 1976 16. Wetmore RF, Handler SD, Potsic WP: Pediatric tracheostomy: Experience during the past decade. Ann Otol Rhino1 Laryngol 91:628-632, 1982
Principles and Practice
Pediatric Tracheotomy: A Review of Technique ANDREW J. HOTALING, MD, WAYNE K. ROBBINS, DO, DAVID N. MADGY, DO, WALTER M. BELENKY, MD
It is well documented that the morbidity, mortality, and complication rates for pediatric tracheotomy are significantly higher than for adult tracheotomy. IF4 With trends toward performing pediatric tracheotomies in an increasingly premature population with less emergent indications, it is essential that techniques be reviewed for any factors that may reduce complications. At Children’s Hospital of Michigan, the same tracheotomy technique has been used since 1985. The technique and experience with 141 patients are reviewed. REVIEW OF THE LITERATURE Postoperative complications from tracheotomy are divided into early and late complications. The most frequently described early complications are accidental decannulations, plugging or cannular obstruction, pneumothorax, and postoperative bleeding.‘-3*5*6 Accidental decannulation is of particular concern as there are several reports of pneumothorax, pneumomediastinum, and even cardiac arrest with attempts at emergent recannulausually detion. 2-4,6-8 Late complications, scribed as occurring after the seventh postoperative day, may also be influenced by operative technique. Accidental decannulation and
From the Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, IL; Department of Otolarynology, Children’s Hospital of Michigan, Detroit, MI; and the Flint Osteopathic Hospital, Flint, MI. Presented at SENTAC, held in Washington, DC, December 9, 1990. Address reprint requests to Andrew J. Hotaling, MD, Loyola University Medical Center, 2160 S First Ave, Maywood, IL 60153. Copyright 0 1992 by W.B. Saunders Company 0196-0709/92/l 302-0009$5.00/O American
Journal
of Otolaryngology,
plugging are frequently noted. Stoma1 granulation, skin erosion, and tracheocutaneous fistula are also observed. Although there are numerous articles that review operative technique, there is no clear consensus on a number of technical aspects. The most controversial issue is the tracheal incision. The options include vertical incision, horizontal incision, inferiorly based flap as described by Bjork, and excision of the anterior tracheal wall.’ Kirchner et al report that excision of the anterior tracheal wall results in tracheal stenosis in the pediatric age group. 7*10 This finding is supported by Tepas et al who noted an increased number of decannulations and tracheal obstruction by granulation tissue, occurring at a mean of 4 days postoperatively using this technique.” Although the vertical incision is most frequently used in children, it is reported by one author to be associated with tracheal stenosis.l Depending on the diameter of the tracheal lumen, the horizontal incision may make cannulation difficult although it is associated with a low degree of stenosis. There is little written about the use of the inferiorly based flap in children although it is frequently used in adults. Although the articles reviewed state that the risk of stenosis is low, follow-up data is lacking.2.12,13 Cosmetically, the direction of the skin incision makes little difference, as reflected by an equal number of proponents for both horizontal and vertical skin incisions. Kirchner argues strongly in favor of the vertical skin incision, stating that “with the horizontal skin incision, the redundant tissue above the incision tends to rest on the shaft of the cannula and to displace its distal end posteriorly.7” He states that the horizontal incision may cause
Vol 13, No 2 (March-April),
1992: pp 115-l 19
115
116
HOTALING
obstruction and mucosal irritation, whereas the vertical incision allows for free movement of the cannula with respiration and deglutition. Management of the thyroid isthmus has also caused a divergence in operative technique. The majority of authors recommend dividing the isthmus only when necessary, otherwise retracting it superiorly or inferiorly to make the tracheal incision. There are a number of authors who recommend division of the isthmus routinely. The stated reasons for routine division are varied but include better visualization of the trachea in the event of accidental decannulation, elimination of constant pressure on the inferior aspect of the cannula displacing the tip anteriorly, and improved control of postoperative bleeding.6*7 One author reports marked interstitial hemorrhage noted in a thyroid gland at the autopsy of a child with significant postoperative bleeding.ll The use of stay sutures lateral to the tracheal incision for the first postoperative week is almost unanimously supported in the literature. One 15-year review by Line et al raises concern, however, that these stay sutures may have contributed to tracheomalacia and flap stenosis in at least two patients.14 For this reason, the authors stopped using stay sutures in the trachea and began suturing the flange of the tube to the skin. In reviewing complications, these authors noted an increase in accidental decannulations during the period when the stay sutures were not used. OPERATIVE
ET AL
platysma are sharply incised in the midline, exposing the subcutaneous fat, which is then excised to expose the anterior cervical fascia. Careful hemostasis is obtained. Frequent digital palpation of the trachea is essential and is performed after each adjustment of retraction. With the midline identified, dissection is performed between the strap muscles to the thyroid isthmus, which is either mobilized superiorly or inferiorly or is divided by suture ligature. The pretracheal fascia is then bluntly dissected from the anterior trachea. After the cricoid is positively identified by palpation and inspection, a trach hook is placed between the cricoid and the first tracheal ring to elevate and stabilize the trachea. A no.-15 blade scalpel is used to incise the trachea horizontally below the second or third tracheal ring. The incision is carried inferiorly at the 2to 3-o’clock and 9- to lo-o’clock positions of the third or fourth tracheal ring using scissors to fit the diameter of the planned tracheostomy tube. Electrocautery is used to obtain hemostasis of the tracheal incisions. This maneuver creates an inferiorly based flap in the anterior tracheal wall. This flap is then sewn bilaterally to the subcutaneous tissue at the inferior margins of the incision using absorbable suture [Fig 1).The stoma created is more secure and less dependent on the tracheotomy tube for patency. Nonabsorbable sutures are placed bilaterally through the cut tracheal ring to serve as traction sutures for the first 3 to 5 postoperative days. Each suture is tied
TECHNIQUE
At Children’s Hospital of Michigan, the same technique for pediatric tracheotomy has been used since 1985. When the decision to perform a tracheotomy is made, the tracheotomy nurse is consulted to begin parental and/ or primary caregiver teaching. All tracheotomies are performed in the operating room under general endotracheal anesthesia. Hyperextension of the neck is achieved with a shoulder roll and maintained by taping the mandible to the head of the table. The skin is injected in a vertical fashion from the cricoid ring inferiorly using 0.5% xylocaine with I:~OO,OOO epinephrine. The skin and
Fig 1. Inferior-bared trap-door tracheotomy incision secured to subcutaneous tissue inferiorly with absorbable suture. Trach hook under cricoid is stabilizing the trachea.
PEDIATRIC
117
TRACHEOTOMY
twice. The first series of knots is placed just anterior to the skin. The second series is placed 4 to 6 cm lateral to the first series. The procedure of placing the tracheotomy tube is rehearsed with the anesthesiologist so that it is understood that the endotracheal tube will be withdrawn superiorly only until it is just above the stoma. The endotracheal tube can then be easily repositioned if there is difficulty with ventilation via the tracheostomy tube. An appropriately sized tracheostomy tube is inserted, and connection is made to the ventilation system. Until the ties are secure, the tracheostomy tube is held in position by a member of the surgical team. Bilateral auscultation of the chest is performed. When adequate ventilation is verified, the tracheostomy tube is then tied in position. The tying is performed by flexing the neck and tying securely so that one finger can be placed under the tie with the neck flexed. The trach hook is then removed. After tying, auscultation is repeated to ensure adequate ventilation. When ventilation is adequate, the endotracheal tube is then removed. Two 1%in to Z-in pieces of l-in cloth adhesive tape are then marked “left do not remove” and “right do not remove.” Each marked piece is placed between the two strands of each stay suture between the two sets of knots to secure the traction sutures to the chest. In the immediate postoperative period, the child is transferred to the intensive care unit (ICU). The child is accompanied from the operating room to the ICU by a member of the surgical team. A stat portable chest x-ray is obtained and reviewed for placement of the cannula, pneumothorax, and pneumomediastinum. The patient is suctioned as needed. The surgical team member reviews the recannulation procedure and the use of traction sutures with the ICU nursing staff. If stable and without other significant problems, the patient can be transferred to a regular floor on the first postoperative day. Suctioning equipment, a spare trach set, the inserting cannula for the tracheotomy tube in use, and humidification are kept at the bedside at all times. The patient may be maintained on an apneaibrachycardia monitor and pulse oximetry as indicated. Discharge planning is initiated in the early postoperative period. The child is monitored closely by the surgical staff
postoperatively. The initial tracheostomy tube change is made by two members of the surgical team on the fifth to seventh postoperative day. DISCUSSION
Several 5- and lo-year reviews of experience with pediatric tracheotomies have documented changing trends.‘-3+5983”.14 Most consistently noted are the changing indications for tracheotomy. In the past, tracheotomy was indicated in the management of inflammatory diseases; currently, these diseases are better managed by endotracheal intubation in an ICU setting in most hospitals. The advent of neonatology and improvement in technology has provided a younger population of patients with tracheotomies.3 Many of these neonates require prolonged intubation due to their prematurity. The more recent advances by surgical subspecialities to correct congenital anomalies of craniofacial, neurosurgical, and cardiac origins account for an increasing percentage of tracheotomies today. With these changes toward more elective indications for tracheostomy, it is essential that complications be minimized by any technical advantage. The use of the inferior-based flap sutured to the subcutaneous tissue provides a secure stoma less dependent on the cannula to maintain patency. This flap decreases the risk of accidental decannulation, the most frequent postoperative complication in most series. Pneumothorax and pneumomediastinum are also frequently associated with emergent attempts at recannulation. These complications can also be limited by use of the inferior-based flap. In the series of 141 pediatric tracheotomies, there have been no documented accidental decannulations, supporting the belief that the inferior-based flap maintains the patency of the stoma during the immediate postoperative period. If required, the lateral stay sutures would facilitate recannulation. The concern has been raised that the Bjork flap may result in a higher incidence of tracheal stenosis in children. However, several animal studies suggest that the inferior-based flap is associated with the lowest incidence of stenosis.l”,15 Lulenski and Batsakis compared
118
vertical and inferior based flap incisions in dogs and found no difference between controls and the inferior-based flap incisions, compared with the vertical incisions that resulted in an 18% decrease in cross-sectional area.l’ These authors suggested that with the vertical incision the tracheostomy tube caused pressure against the cut edges of the cartilaginous rings. The pressure resulted in inhibition of the normal healing process, as demonstrated microscopically by the lack of an inflammatory response. In the literature reviewed, there is no evidence that the inferiorbased flap increases the incidence of tracheal stenosis. At Children’s Hospital of Michigan there have been 5 patients with tracheal stenosis and 15 patients with suprastomal anterior tracheal wall collapse. Of the 5 patients noted to have tracheal stenosis, 3 have been decannulated and required no further treatment. Two of the 5 patients remain with tracheotomies. In the series of 15 patients noted with suprastomal collapse of the anterior tracheal wall, 9 have been decannulated without difficulty or further treatment. Six of the patients remain with tracheotomies. Of note, 1 of these patients, a neonate was found to have an anterior neck perithyroid abscess that was discovered at the time of tracheotomy. The anterior tracheal collapse in this patient may have been the result of this pre-excising abscess. It is thought that there may be an increased rate of tracheocutaneous fistula, which is addressed preoperatively with the parents. Twenty-three percent of the decannulated patients had a tracheocutaneous fistula that required closure. The elective closure of a tracheocutaneous fistula is preferable to major morbidity or even mortality from accidental decannulation. Other series report tracheocutaneous fistula rates of 13% to 35%.29'6 Although the choices of skin incisions probably have little significance in reducing postoperative complications, the vertical incision has some merit. As noted in the literature, the vertical incision allows for movement of the tracheotomy tube and may decrease displacement of the tip of the cannula into the posterior tracheal wall, limiting granulation tissue and possibly eliminating one source of tubal obstruction. As noted earlier, a horizontal skin incision may cause a reundancy of tissue
HOTALING
ET AL
below the incision, which tends to increase the distance between the skin and the tracheal incisions. This redundant tissue may make recannulation more difficult, especially in an emergent situation. More practically, however, the vertical incision is easily extended if required. Routine division of the thyroid isthmus has theoretical advantages. Although division is not routine in this technique, division of the isthmus is performed when necessary. The incidence of postoperative bleeding associated with the thyroid gland is very small by reports in the literature. Without strong evidence in favor of division, this point is best left to clinical judgement rather than ritualistic procedure. Finally, postoperative bleeding is always a concern in tracheotomy. Removing the subcutaneous fat may be a factor in decreasing postoperative bleeding. Further, removal of this tissue allows for better visualization of the trachea, both at the time of surgery and in the event of accidental decannulation. CONCLUSION
With the complication rate of 20% to 49% and mortality of 2% to 8.5% associated with pediatric tracheotomies, technical aspects must be examined closely.2~3*“*‘4~16 Having reviewed the literature and the experience at Children’s Hospital of Michigan, there are several aspects of this surgical technique that are effective in minimizing postoperative complications. Most significant is the use of the inferior-based tracheal flap to create a more secure stoma. Resection of the subcutaneous fat has also limited postoperative oozing and improved visualization of the trachea for cannulation. In 141 tracheotomies performed since 1985, there have been no documented accidental decannulations. This technique appears to be safe and effective in limiting complications. REFERENCES 1. Crysdale WS, Feldman RI, Naito K: Tracheotomies: A lo-year experience in 319 children. Ann Otol Rhino1 Laryngol 94:439-443, 1988 2. Gilmore BB, Mickelson SA: Pediatric tracheotomy:
PEDIATRIC
TRACHEOTOMY
Controversies in management. Otolaryngol Clin North Am 19:141-151, 1986 3. Kenna MA, Reilly JS, Stool SE: Tracheotomy in the preterm infant. Ann Otol Rhino1 Laryngof 96:68-71, 1987 4. Tepas JJ: Tracheostomy in infants and children. Ear Nose Throat J 62484-488, 1983 5. Carter P, Benjamin B: Ten-year review of pediatric tracheotomy. Ann Otol Rhino1 Laryngol92:398-400, 1983 6. Gerson CR, Tucker GF: Infant tracheotomy. Ann Otol Rhino1 Laryngol 91:413-416, 1982 7. Kirchner JA: Avoiding problems in tracheotomy. Laryngoscope 96:55-57, 1986 8. Stool SE, Eavey RD: Tracheotomy, in Bluestone CC, Stool SE, Scheetz MD (eds): Pediatric Otolaryngology (ed 2) Philadelphia, PA, Saunders, 1990, pp 1226-1243 9. Bjork VO: Partial resection of the only remaining lung with aid of respirator treatment. J Thorac Cardiovasc Surg 39:179-188, 1960 10. Arola MK, Inberg MV, Puhakka, H: Tracheal steno-
119
sis after tracheostomy and arter orotracheal cuffed intubation. Acta Chir S&d 147:183-192, 1981 11. Tepas JJ, Heroy JH, Shermeta DW, et al: Tracheostomy in neonates and small infants: Problems and pitfalls. Surgery 89:635-639, 1981 12. Lulenski GC. Batsakis JG: Tracheal incision as a contributing factor to trachea{ stenosis. Ann Otolaryngol 84:781-786, 1975 13. Price DG: Techniques of tracheostomy for intensive care unit patients. Anesthesia 38:902-904, 1983 14. Line WS, Hawkins DB, Kahlstrom EJ, et al: Tracheotomy in infants and young children: The changing perspective 1970-1985. Laryngoscope 96:510-515, 1986 15. Mendez-Picon G, Ehrlich FE, Salzberg AM: The effect of tracheostomy incisions on tracheal growth. J Pediatr Surg 5:681-684, 1976 16. Wetmore RF, Handler SD, Potsic WP: Pediatric tracheostomy: Experience during the past decade. Ann Otol Rhino1 Laryngol 91:628-632, 1982
