figure 11-22 Correct placement of tracheostomy tubes, when necessary, to manage postintubation tracheal stenoses. A, A stomal stenosis is best treated by locating the new tracheostomy in the stenotic segment, never below it. B, A high cervical cuff stenosis is best treated by locating the new tracheostomy in the stenotic segment, never below it. C, A low substernal cuff stenosis is managed by tracheostomy in a prior cervical site or at the conventional (2d-3d ring) site, with placement of a tube long enough to extend through the distal stenosis. D, If a cervical stenosis of considerable length has been managed by tracheostomy placed distal to it, the tracheostomy site should be relocated to the stenosed segment. The inferior tracheostomy is allowed to heal, thus recapturing a usable distal tracheal length. T tubes are also placed in the same locations in each case for longer-term management ofpatients, providing voice and more normal respiration.
the best opportunity for successful reconstruction lies in the initial surgical attempt. Second trials may or may not succeed and a third attempt entails even more risk. Tracheal reconstructive procedures should not be undertaken without considerable study and experience. Silicone or expandable stents, even if coated, appear inadvisable to treat benign stenosis, since they not only produce severe stenotic lesions but may make future definitive repair impossible (see Chapter 40, "Tracheal and Bronchial Stenting").34
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