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\begin{document}

\title{Tracheocutaneous fistula- A surgical challenge}



\author[1]{PRAMOD CHIRAKKAL}%
\author[1]{Amira Al Hail}%
\affil[1]{Hamad Medical Corporation}%


\vspace{-1em}



  
  \date{May 08, 2024}


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\begin{abstract}
We are experienced a challenge for the surgeon for tracheocutaneous
fistula closure in managing such a complication such as chronic cough,
infection and other co-morbidities. The need for a secondary closure is
also warranted when the stoma does not close on itself within a
specified time.%
\end{abstract}%



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\textsubscript{\textbf{TRACHEO-CUTANEOUS FISTULA- A Surgical challenge}}

\textsubscript{\textbf{ABSTRACT}}

\textsubscript{Tracheostomy is a general surgical procedure performed by
many surgeons on a routine basis. A tracheostomy orifice closes by
secondary intention in many routine cases\textbf{.} The following case
report is about a 54-year-old patient diagnosed with squamous cell
carcinoma of the right vocal cord who underwent micro laryngeal excision
with tracheostomy followed by radiation therapy. After 2 years, on
decannulation he had a persistent tracheocutaneous fistula. A
tracheocutaneous fistula is commonly regarded as a pathological
complication of temporary tracheostomy that results due to failure of
spontaneous tracheostome closure post decannulation\textbf{.} Various
factors present a challenge for the surgeon in managing such a
complication such as chronic cough, infection and other co-morbidities.
The need for a secondary closure is also warranted when the stoma does
not close on itself within a specified time.}

\textsubscript{Keywords:}

Tracheostomy, Pectoralis major musculocutaneous flap, fistula

Key Clinical Message:

Tracheocutaneous fistula presents a challenge to the surgeon as
different factors affects its formation and healing. A multidisciplinary
approach and proper patient counselling, duration of
cannulation.comorbidies helps in prognosis and outcome.

\textsubscript{\textbf{CASE REPORT}}

\textsubscript{The patient was a 54-year-old male who is diagnosed with
squamous cell carcinoma of the right vocal cord for which he had
undergone microlaryngeal surgery along with tracheostomy for the same in
July 2012. He then underwent intensity modulated radiotherapy. Since
then, the patient has been on tracheostomy tube. Patient was
decannulated following laryngoscopic assessment on April 2015. A
strapping was done to seal the tracheostome. A month later, on follow
up, the tracheostome was found to be still patent with an air leak
(Figure 1). A secondary suturing was attempted to close the fistula.
Despite this attempt the fistula persisted due to his chronic cough. The
patient was then posted for a flap cover to close the fistula. After
admission for the same, he developed severe bronchitis for which he was
treated medically. A bronchoscopy showed inflammed bronchus and a
broncheo-alveolar lavage showed pseudomonas aeruginosa growth for which
he was treated with culture sensitive antibiotics and steroids. During
this course, he developed steroid induced hyperglycemia with a
derangement of his renal parameters and was under the diabetologist and
nephrologist care. Post recovery and after getting the medical
clearance, he underwent a Pectoralis Major Musculocutaneous Flap cover
in June 2015 (Figure 2). On the first post op day, he had an episode of
transient unresponsiveness with stable vitals. He had no chest pain or
hypoglycemic episodes. Examination revealed bilateral subcutaneous
emphysema over the chest and face. Chest Xray showed no signs of
pneumothorax. Screening ECHO showed a good LV systolic function with no
pericardial effusion or evidence of Acute Coronary Syndrome. Blood test
for troponin T was negative. He was closely monitored in the Intensive
Care Unit. He also received a unit of packed cells for his drop in
hemoglobin post op. he was discharged from the hospital and was advised
to follow up in the OPD for dressing. After a week from discharge, he
came to the OPD with complaints of pain in the surgical donor site of
the flap. Examination revealed an abscess at the surgical site which was
drained and the pus was sent for culture which later reported as
carbapenem resistant enterobacteria (Figure 3). He was treated with IV
antibiotics and daily dressing of the surgical site wound was done.
After 10 days the wound healed well and was later discharged from the
hospital.}

\textsubscript{\textbf{DISCUSSION}}

\textsubscript{A tracheocutaneous fistula is commonly regarded as a
pathological complication of temporary tracheostomy that results due to
failure of spontaneous tracheostome closure post decannulation. Chronic
TCF can impair the quality of life, vocalization and the need for local
hygiene with frequent hospital visits (1). Although most of these
fistulae close spontaneously after decannulation or after local
debridement, a significant percentage do not and require some form of
surgical closure (2). Despite its clinical impact, there are few studies
in the literature on its risk factors and pathogenesis. The incidence of
fistula formation is known to be related to the cannulation time. Kulber
et al. reported that fistulas do not develop if the cannulation period
is less than 16 weeks (3). Incidences of TCF up to 70\% have been
reported when tracheostomies were maintained for more than 16 weeks (3).
In this case, the cannulation time exceeded 2 years. Furthermore, other
factors such as previous irradiation of neck, previous tracheostomy and
obesity have been suggested to be risk factors for TCF (4). Chronic
cough and aspiration could play an important role favoring the onset of
TCF, independent of decannulation timing and may also influence the
surgical failure and relapse rate. In this case, the patient being a
known COPD case, the status of the lung functions was already
compromised prior to tracheostomy and the same worsened due to the
prolonged cannulation time. A multidisciplinary approach is hence needed
for cases like this. TCF closure can be challenging since the laryngeal
airway can be suboptimal and abnormal increases in subglottic pressure
during the expiration phase can be present (5-7).}

\textsubscript{In conclusion, TCF presents a challenge to the surgeon as
different pathogenic factors affect its formation and healing. A
multidisciplinary approach is very much in need for a patient with
different medical ailments. Proper patient counselling, duration of
cannulation, assessment of risk factors and management of the
co-morbidities, all help in determining the incidence and prognosis of
tracheocutaneous fistula.}

Author Contribution

The author confirms sole responsibility for the following: study
conception and design, data collection, analysis and interpretation of
results, and manuscript preparation

\textsubscript{\textbf{Conflict of interest:}}

The authors whose names are listed above certify that they have NO
affiliations with or involvement in any organization or entity with any
financial interest and no conflict of interest in the subject matter or
materials discussed in this manuscript.

\textsubscript{\textbf{Acknowledgement statement:}}

\textsubscript{\textbf{I would like to express my special thanks of
gratitude to all my colleagues and for their able guidance and support
in completing my case report.}}

\textsubscript{\textbf{REFERENCES}}

\textsubscript{Berbholz L, Vail S, Berlet A. Management of trachea
cutaneous fistula. \emph{Arch Otolaryngol Head Neck
Surg}1992;118:869-71}

\begin{itemize}
\tightlist
\item
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  technique for primary closure of long-term tracheostomy} . Otolaryngol
  Head Neck Surg 2005; 132:15}
\item
  \textsubscript{Kulber H, Passy V. \emph{Trachea cutaneous closure and
  scar revision} . Arch Otolaryngol 1972; 96:22-6}
\item
  \textsubscript{Khaja SF, Fletcher AM, Hoffam HT. \emph{Local repair of
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\item
  \textsubscript{De Virgilio A, Fusconi M, Gallo A, et al. \emph{The
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\item
  \textsubscript{Bussu F, Paludetti G, Almadori G, et
  al.\emph{Comparison of total laryngectomy with surgical and
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\item
  \textsubscript{De Vincentiis M, De Virgilio A, Bussu F, et
  al.\emph{Oncological results of the surgical salvage of recurrent
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\end{itemize}

figure 1 Non healing tracheostoma

figure 2- Pectoralis musculocutaneous flap and stoma closure

figure 3 -- Pus discharge from donor site

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