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Oncological Tracheostomy
Table 3 Scoring system devised by Cameron etal. to guide airway management after major head
and neck surgery
Scoring factor Score
Tumor site Cutaneous 0
Mouth Buccal mucosa
Maxilla
Mandibular alveolus
Anterior tongue
Floor of mouth
Oropharynx Soft palate
Anterior pillar
Tonsillar pillar
Posterior tongue
Hypopharynx
Mandibulectomy No
Yes
Bilateral neck dissection No
Yes
Reconstruction None
Radial forearm free ap
Other
Int. J.Oral Maxillofac. Surg. 2009
0
0
1
1
2
3
3
4
4
4
0
1
0
3
0
2
3
179
conservative surgery and exclusive radiation an effective course of treatment for
transglottic tumors. According to their retrospective study, temporary or permanent
tracheostomy stands among the most frequent complications in patients undergoing
vocal conservation surgery followed by irradiation or not. The need for permanent
tracheostomy is also an important prognostic factor in 5-year survival [17].
Pretreatment tracheostomy has been related to a higher risk of stomal recurrence
and a poor prognosis [17]. Nevertheless, Modlin and Ogura found no difference in
stomal recurrence between patients who did and those who did not undergo pretreatment tracheostomy [18].
Organ preservation, an evolution in advanced laryngeal cancer treatment, originated
from the Veteran Affairs study in 1991 and the Radiation Therapy Oncology Group
91-11 study in 2003, which determined primary chemoradiation as being standard treatment for advanced tumors. Its use imposed an increase in functional complications and
a decrease in overall survival in older patients and those with T4 disease [19]. According
to O’Neill etal., 19% of patients who underwent total laryngectomy and 22% of patients
who underwent organ preservation had a tracheostomy prior to treatment.
Jefferson etal. demonstrated that persistent tracheostomy was associated with
pretreatment tracheostomy, subglottic tumor extension, three-dimensional conformal radiotherapy, and postradiotherapy cervical lymphadenectomy in larynx primaries, and pretreatment tracheostomy and feeding tube dependency in hypopharynx
primaries. Tracheostomy was not associated with worse local control. Furthermore,
organ preservation may not restore prelaryngeal decits. Normally these reports
assess swallowing—not airway—impairment and factors associated with tracheostomy dependence [20].
180
Fig. 12 Total glossectomy
followed by bulky ap
reconstruction, with
expected important
swallowing function loss
and airway structure
collapse
Table 4 Scoring system devised by Kim etal. for elective tracheostomy in oral cancer
Oral cancer
Elective tracheostomy scoring system for severe oral disease patients. J Korean Assoc Oral
Maxillofac Surg 2014
PA posterior–anterior X-ray, TNMTumor–Node–Metastasis scoring system
Scoring factor Subsection
TNM stage I
II
III
IV
Reconstruction No reconstruction
Soft tissue free ap
Soft+hard tissue free ap
Chest PA No pathological nding
Pathological nding
Number of systemic diseases None
1–2
≥3
C.E.S.R. Barreira et al.
Score
0
1
2
3
0
1
2
0
1
0
1
2
Organ preservation is indicated not only for laryngeal cancers but also for laryngopharyngeal and hypopharyngeal cancers.
Tracheostomy inOrgan Preservation Laryngeal Surgery
Organ preservation laryngeal surgery is a procedure encompassing partial laryngeal
removal and functional preservation (speech, swallowing, and respiration), with
local control and cure and without the need for a permanent tracheostomy [21]. The
aim is to preserve airow through the larynx and laryngeal sphincter function, preventing the need for a permanent tracheostomy [22].
Oncological Tracheostomy
Fig. 13 Supraglottic
laryngectomy
181
Vertical Partial Laryngectomy
Vertical partial laryngectomy stands for a range of procedures, from cordectomy to
extended hemilaryngectomy. The extent of surgery determines whether tracheostomy is necessary.
Horizontal Partial Laryngectomy
Supraglottic Laryngectomy
In this technique, described by Alonso in 1939, tracheostomy is part of the surgical
procedure and the aim is to perform decannulation as soon as possible, with safety.
The technique is executed with the concern being to avoid anastomosis tension, in
the same fashion as supracricoid laryngectomy (Fig.13).
Supracricoid Laryngectomy
Supracricoid laryngectomy was rst described as an organ preservation surgery
technique aimed at achieving functional and oncological results; therefore, the need
for a permanent tracheostomy is avoided. A temporary tracheostomy is mandatory.
The trachea must be released inferiorly (cervicomediastinally), avoiding recurrent
laryngeal nerve injury. Tracheostomy should be performed as distal from cricoid as
possible, since the anastomosis (cricohyoidoepiglottopexy [CHEP] or cricohyoidopexy [CHP]) should bear no tension. Complications such as aspiration and pneumonia are causes of failed decannulation [21].
The cricoarytenoid unit is a functional laryngeal structure after supracricoid laryngectomy. Normally, patients bearing two arytenoids accomplish earlier decannulation than patients undergoing one arytenoid resection and may accomplish
better functional results [21–24]. Postoperative radiotherapy normally imposes longer and more arduous rehabilitation regarding functional results [22]. The protocol
for decannulation varies according to institutional practice. All patients undergo
182
C.E.S.R. Barreira et al.
progressive decannulation with downsizing of the tracheostomy tube, applying a
cufess tracheostomy tube and capping the tracheostomy tube, with laryngoscopy
control [22, 23, 25] (Figs.14 and 15).
Near-Total Laryngectomy
This technique, described by Pearson in 1980, is indicated for patients with advanced
laryngeal–hypopharyngeal tumors restricted to one side of the larynx–hypopharynx. A shunt between the trachea and pharynx is created through neopharynx closure, and tracheostomy is paramount. The intrinsic laryngeal musculature with
ipsilateral nerve preservation controls the shunt, pumping air from the lung to the
pharynx. There is no need to perform tracheostomy as distal from cricoid as possbile. The procedure gives the patient a physiological voice at the expense of requiring a permanent tracheostomy [26, 27] (Figs.16 and 17).
Fig. 14 Supracricoid
laryngectomy
Fig. 15 Cricohyoidoepig
lottopexy
Oncological Tracheostomy
Fig. 16 Near-total
laryngectomy
Fig. 17 Shunt in
near-total laryngectomy
183
Endoscopic Technique
Normally, the endoscopic technique obviates the need for a tracheostomy.
Total Laryngectomy
Patients have to live with a permanent tracheostomy when total laryngectomy is
performed. The indications for tracheostomy prior to oncological surgical treatment are due to airway blockage by tumor growth and/or laryngeal edema, as claried before in the indications in oncological patients. Care should be taken to avoid
tumor violation and spillage concerning subglottic laryngeal lesions and not to
perform tracheostomy so distal from cricoid preventing tensionless stoma maturation to the skin.
184
C.E.S.R. Barreira et al.
Questionnaires (Quality ofLife)
Questionnaires are used to assess the patient’s quality of life. There are several
questionnaires available, and they represent a tool for subjective assessment from
the patient’s perspective. These questionnaires are not necessarily head and neck
cancer specic but may evaluate language, speech, and communication. The World
Health Organization’s International Classication of Functioning, Disability and
Health (ICF), issued in 2001; the Voice Handicap Index; and the North American
questionnaires Functional Assessment of Cancer Therapy and University of
Washington Quality of Life Questionnaire are some examples. Undoubtedly,
patients who bear a tracheostomy have some level of impairment and some loss of
quality of life [28]. The pictures presented in this chapter were taken after patient’s
consent and with purpose to learn and to be used exclusivelly in this context.
References
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2. Lee HJ, Kim JK, Choi SY.The evaluation of a scoring system in airway management after oral
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hospital experience. Laryngoscope. 2005;115:2101–4.
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13. Castling B, Telfer M, Avery S.Complications of tracheostomy in major head and neck cancer
surgery; a retrospective study of 60 consecutive cases. Br J Oral Maxillofac Surg. 1994;32:3–5.
14. Cameron M, Corner A, Diba A, Hankins M.Development of a tracheostomy scoring system
to guide airway management after major head and neck surgery. Int J Oral Maxillofac Surg.
2009;38(8):846–9.
15. Kim YH, Kim MY, Kim CH. Elective tracheostomy scoring system for severe oral disease
patients. J Korean Assoc Oral Maxillofac Surg. 2014;40:211–9.
16. Kruse-Lösler B, Langer E, Reich A.Score system for elective tracheotomy in major head and
neck tumour surgery. Acta Anaesthesiol Scand. 2005;49:654–9.
17. Bharat M, Marks JE, Ogura JH.Transglottic carcinoma. Cancer. 1984;53:151–61.
Oncological Tracheostomy
18. Modlin B, Ogura JH. Post-laryngectomy tracheal stomal recurrences. Laryngoscope.
1969;(2):239–50.
19. O’Neill CB, O’Neill JP, Atoria CL, Baxi SS, Henmann MC, Ganly I, Elkin EB.Treatment
complications and survival in advanced laryngeal cancer: a population-based analysis.
Laryngocope. 2014;124:2707–13.
20. Jefferson GD, Wenig BL, Spiotto MT. Predictors and outcomes for chronic tracheos-
tomy after chemoradioation for advanced laryngohypopharyngeal cancer. Laryngoscope.
2016;126:385–91.
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2009;1:12.
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Flint PW, Webster K. Supracricoid laryngectomy outcomes: the Johns Hopkins experience.
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23. Laccourreye H, Laccourreye O, Weinstein G, Menard M, Brasnu D.Supracricoid laryngec-
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24. Leszezynska M, wierzbicka M, Tokarski M, Szyfter W.Attempt to improve functional out-
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25. Bron L, Brossard E, Monnier P, Pasche P.Supracricoide partial laryngectomy with cricohyoi-
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2000;110:627–34.
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27. Maamoun SI, Amira G, Younis A.Near total laryngectomy: a versatile approach for voice res-
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185
Mediastinal Tracheostomy
PauloJoséde CavalcantiSiebra, RuiterDiegode
MoraesBotinelly, TerencePiresde Farias,
AlexandreFerreiraOliveira, andFernandoLuizDias
Introduction
Mediastinal tracheostomy (MT) is the construction of a stoma on the anterior chest
by using the intrathoracic trachea when there is insufcient length for reanastomosis with the remaining trachea or for a traditional suprasternal tracheostomy. This
procedure requires a laryngectomy (if not done previously) associated with removal
of the upper sternum, the medial third of the clavicles, and eventually the proximal
third of the rst and second ribs, to provide access to the intrathoracic trachea [1–3].
Few surgeons or institutions have extensive experience of this procedure, due to its
rarity, complexity, and association with high morbidity. In the literature, there are
some case series with small sample sizes, but with acceptable results [4].
P.J. de CavalcantiSiebra, M.D. • R.D. de MoraesBotinelly, M.D. (*)
Head and Neck Surgeon, Fellow of Head and Neck Surgery at Brazilian
National Cancer Institute, Rio de Janeiro, RJ, Brazil
e-mail: pj_siebra@hotmail.com; ruiterdiegob@hotmail.com
T.P. de Farias, M.D., Ph.D., M.Sc., Researcher.
Department of Head and Neck Surgery, Brazilian National Cancer Institute—INCA,
Rio de Janeiro, RJ, Brazil
Department of Head and Neck Surgery, Pontical Catholic University,
Rio de Janeiro, RJ, Brazil
e-mail: terencefarias@yahoo.com.br
A.F. Oliveira, M.D., Ph.D.
Department of Surgery, Federal University of Juiz de Fora,
Juiz de Fora, MG, Brazil
F.L. Dias, M.D., Ph.D., M.Sc., F.A.C.S.
Head and Neck Surgery Department, Brazilian National Cancer Institute—INCA,
Rio de Janeiro, RJ, Brazil
Head and Neck Department, Pontical Catholic University of Rio de Janeiro, Rio de Janeiro,
RJ, Brazil
© Springer International Publishing AG 2018
T.P. de Farias (ed.), Tracheostomy, https://doi.org/10.1007/978-3-319-67867-2_11
187
188
P.J. de CavalcantiSiebra et al.
History
In 1942, Watson planned a procedure for the treatment of a squamous cell carcinoma 4cm above the carina. The patient had undergone a laryngectomy followed
by radiotherapy 15years previously. A “V” portion of the sternum was resected and
skin aps were mobilized to allow closure of the tracheostomy margins [23].
In 1952, Kleitsch removed a patient’s upper sternum and inserted a polyethylene
tube for MT [21].In the same year, Minor, after removal of a recurrent carcinoma in
a tracheostoma, fashioned skin aps into the shape of a tube through a sternal opening to connect with the trachea [22]. In 1959, Waddell and Cannon pulled a tracheal
segment on the right of the ascending aorta and anastomosed it with a skin tube created with aps from the anterior chest region through an opening in the sternum. Of
the four patients who underwent this procedure, two died of massive bleeding [17].
In 1962, Sisson et al. resected a large piece of skin along with a tumor and
removed the notch and the heads of both clavicles in surgery for recurrence of laryngeal carcinoma in the stoma. Skin aps were mobilized to the superior closure of the
stoma and the lower failure was covered with skin grafts. After undergoing the procedure, two patients died from postoperative bleeding by the innominate artery, and
the pectoralis muscle (PM) ap began to be interposed between the trachea and the
innominate artery [15].
In 1966, Grillo fashioned a large bipedicled total thickness ap from the skin of
the anterior chest region through two main horizontal incisions in an effort to eliminate the tension in the tracheocutaneous anastomosis responsible for poor healing
and the threat of bleeding from the innominate artery. This aps reaches the terminal stump of the trachea in the mediastinum, which was accessed by removing the
notch and sternal portions of both clavicles and the rst and second costal cartilages.
The stoma emerged at the center of the ap, requiring only a simple suture [19].
Indications
The patient must be carefully selected for this procedure due to its complexity,
potential for complications, degree of deformity, and postoperative sequelae. The
reconstruction of the alimentary tract should be taken into consideration as, according to necessity, there will be a considerable increase in the complexity of the surgery. Thus, a good preoperative evaluation becomes crucial. The patient needs a
good performance status with good heart and lung function, and must be well nourished and psychologically prepared for the deformities and sequelae of the resection
and reconstruction. A history of abdominal surgery inuences the type of reconstruction. A history of cervical radiotherapy compromises the tracheal circulation,
which increases the risk of ischemia and makes it more difcult to access the large
vessels of the neck for a microsurgical anastomosis [5, 6].
According to Conti etal., the main indications for MT are malignant neoplasms
of the subglottic region extending to the proximal trachea, a recurrence in stoma
after laryngectomy, and a well-differentiated thyroid carcinoma with tracheal
Mediastinal Tracheostomy
189
Table 1 Indications for
mediastinal tracheostomy
Indication
Malignant neoplasm of the subglottic region,
extending to the proximal trachea
Recurrence of stoma after total laryngectomy
Well-differentiated thyroid carcinoma with
tracheal invasion
invasion, after either curative or palliative resection (Table 1). The recommended
minimum length of the residual trachea for this procedure is 5.0 cm. The same
authors also recommend chemotherapy and radiation associated with tracheal stenting for cases of cervical esophageal cancer with tracheal invasion; the 3-year survival rate is just 11% after a radical procedure.
The presence of metastases is not an absolute contraindication to this procedure.
However, in these cases, other methods for palliation with less morbidity should be
considered, such as radiotherapy or stent placement [4].
The main contraindications to MT are invasion or involvement of the great vessels, distal trachea invasion of 3.0–4.0cm above the carina, column or prevertebral
fascia invasion, and the presence of disease in the bronchial lumen [7].
Description oftheProcedure andPerioperative Care
The most commonly used incisions are the collar incision and the bipedicled/apron
incision. In cases of recurrence in a previous tracheostoma, the peritracheostoma
skin should be resected (Fig.1).
In the case of a collar incision, a platysmal subcutaneous ap is made to expose
the larynx, trachea, sternocleidomastoid, and carotid sheaths. The lower ap permits better exposure of the anterior thoracic wall. Using a surgical saw, a resection
is done of the middle third of the clavicle, sternal notch, and cartilaginous limit of
the rst two ribs, with preservation of bilateral internal thoracic arteries (Figs.2 and
3). The need to extend the resection to the second rib depends on the length of the
remaining trachea. With this, the surgeon has a good view of the upper mediastinal
structures.
Prior to use of the saw, digital dissection of the posterior wall of the sternum is
recommended.
The trachea is divided obliquely to facilitate skin suturing (Fig.4). The inferior
portion is reintubated and the superior portion is resected along with the affected
structures (Fig.5). After that, the trachea is released from the esophagus by blunt
dissection, with preservation of the vascularization (Fig. 6). When the tracheal
stump causes compression of large vessels, it is transposed inferiorly through the
innominate artery to decrease the distance from the skin and to prevent anastomosis
tension, reducing the risk of peristomal dehiscence, mediastinitis, and rupture of
large vessels (Fig.7).
For closure of the defect and fashioning of the tracheocutaneous anastomosis, use of
myocutaneous aps is recommended to protect the large vessels and avoid tension