Recapture of Tracheal Length

In some patients, a tracheostomy has been made just above or below a lengthy segment of tracheal stenosis, as emergency treatment for the stenosis, unfortunately even where the stenotic segment was accessible in the neck. In some, a stoma has been located below a stenosis as a safeguard for repeated laser treatments of the stenosis. These compound the length of lesions, which might otherwise have been easily corrected by resection. The stoma may lie so close to the area of stenosis that there is not a bridge of normal enough trachea left between the stoma and stenosis to permit dependable anastomosis. Resection of the new tracheal stoma, along with the long adjacent stenosis, may result in excessive anastomotic tension. In such a patient, the recent tracheostomy may be abandoned and allowed to heal (Figure 24-20). This may recapture 1.0 to 2.0 cm of trachea, adequate for reconstruction.16 The patient is observed in hospital without a tracheostomy

figure 24-19 (continued) Suprahyoid laryngeal release. C, The lesser cornua of the hyoid with the chon-droglossus muscles are transected. The digastric muscle slings attaching to the hyoid are left intact. The hyoid itself is divided on both sides anterior to the digastric attachments and lateral to the lesser cornua. D, The suprahyoid membrane is opened and the preepiglottic space entered.

figure 24-19 (continued) Suprahyoid laryngeal release. C, The lesser cornua of the hyoid with the chon-droglossus muscles are transected. The digastric muscle slings attaching to the hyoid are left intact. The hyoid itself is divided on both sides anterior to the digastric attachments and lateral to the lesser cornua. D, The suprahyoid membrane is opened and the preepiglottic space entered.

during stomal healing, with periodic dilations as needed to maintain the airway. This is usually preferable to inserting an endotracheal tube, which causes inflammation, or to locating another tracheostomy at a remote distance since this may limit mobility. If any inlying stent is used to temporize, it should be of silicone so that it will be easily removable with minimal injury to the trachea. If the stenosis is accessible in the neck, the tracheostomy is replaced in the damaged segment, which is ultimately to be resected (Figure 24-21) while waiting for the prior stoma to heal. After the offending stoma has sealed sufficiently (usually within 2 weeks) and some regression of inflammation has occurred, then resection of the stenotic segment with primary anastomosis is accomplished. These considerations do not apply where the existing stoma is remote from the lesion or where its inclusion in resection will not unduly lengthen the resection (Figure 24-22).

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