Author(s)
Andrew J. Lerrick, MD
Rowena Abasolo, APN, CNP
Affiliation(s)
Head & Neck Associates, S.C.
Abstract:
Introduction Closure of a tracheo-cutaneous fistula results in air escape if adequate tracheal occlusion cannot be achieved. Allogenic tissue is an effective means to provide internal bulk in patients with insufficient cervical soft-tissue following anterior compartment neck dissection, compounded by the de-vascularizing effects of radiotherapy. Surgical Technique The atrophic fistula tract skin is incised circumferentially, elevated subcutaneously, inverted, trimmed (if necessary), and sewn to itself in the subepithelial layer. After radiation the sternothyroid and sternohyoid muscles are fibrotic, minimally elastic, and, if the ansa cervicalis was previously sacrificed, atrophic. Extended dissection is necessary to adequately free the muscles to permit medial advancement. While the strap muscles are temporarily retracted medially, a pre-tracheal dead-space is suspected if air escape occurs during forceful ventilation. The void can be filled by layering an allogenic graft in the defect, much like a ribbon. Ordinarily, three to five folds are necessary. The strap muscles are then re-approximated in the midline, over-sewing the folded graft. An air-tight seal is confirmed using saline to check for bubbles during high-pressure ventilation. A Penrose drain is temporarily placed for decompressive purposes in the unlikely event of air escape post-operatively. Conclusions Subcutaneous emphysema and wound breakdown are apt to occur if inverted skin derived from the tract of a tracheo-cutaneous fistula is not supported by underlying soft-tissue. In the setting of deficient muscle these morbidities can be averted using a layered allogenic graft placed sub-muscularly as an internal bolster, which may preclude the need to harvest more distant tissue.