Stomal Stenosis

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Stomal Stenosis

• Andrew Murray
• Study Day
• September 2007

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Stomal Stenosis

• Stoma requirements

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Stomal Stenosis

• Stoma requirements
• Large enough not to need stented
• Allow clearance of secretions
• Allow respiration
• Occludable for T-O speech
• 4-42 of post-laryngectomy stomas are stenosed

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Stomal Stenosis

• Montgomery classification
• Vertical slit
• SCM heads
• Concentric
• Cicatricial scar
• Inferior shelf
• Redundant skin
• Not particularly clinically useful

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Stomal Stenosis

• Other definitions
• Revision surgery is required
• Size is not only consideration
• gt50 reduction can lead to resp compromise in
  chronic lung disease
• May cause no problem in normal lung

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Stomal Stenosis

• Patient Factors
• Postulated
• Fat neck, enlarged thyroid, bulky SCM, defective
  tracheal rings, steroids, keloid, poor nutrition
• Irradiation
• Unclear
• Multivariate analysis no effect
• Sex

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Stomal Stenosis

• Surgical Factors

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Stomal Stenosis

• Surgical Factors
• How the trachea is divided
• Where the stoma is sited
• Laryngectomy tube
• Primary TOP
• Neck dissection
• Pec major
• Post-op wound complications

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Stomal Stenosis

• Surgical Factors
• How the trachea is divided

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Stomal Stenosis

• Straight

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Stomal Stenosis

• Straight
• Complete ring supports the stoma
• Avoids infection granulations of exposed
  cartilage
• Cut immediately below ring 6 stenosis

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Stomal Stenosis

• Bevelled

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Stomal Stenosis

• Bevelled
• Larger cross sectional area
• Better fit to skin ? less tension

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Stomal Stenosis

• Flap

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Stomal Stenosis

• Flap
• Umpteen variations
• All place extra tissue in the circumference
• Break up the cicatricial scar
• 0-13 stenosis rate

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Stomal Stenosis

• Flaps

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Stomal Stenosis

• Straight v bevelled v flap
• 75 v 33 v 0
• 29 v 15 v 8
• Small numbers

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Stomal Stenosis

• Surgical Factors
• How the trachea is divided
• Where the stoma is sited

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Stomal Stenosis

• In main incision
• Larger stoma from lateral pull
• In separate incision
• Less traction lower in neck
• Gentle, even, circumferential traction
• Good blood supply all round
• Trifurcations avoided
• Movement of neck less important

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Stomal Stenosis

• Main incision v separate incision
• NA v 4-13
• Watkinson not important

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Stomal Stenosis

• Surgical Factors
• How the trachea is divided
• Where the stoma is sited
• Laryngectomy tube

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Stomal Stenosis

• May be harmful, beneficial or have no effect
• !

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Stomal Stenosis

• Surgical Factors
• How the trachea is divided
• Where the stoma is sited
• Laryngectomy tube
• Primary TOP

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Stomal Stenosis

• TOP allows saliva to drain into stoma
• Needs to be obturated
• Two studies show significance of primary puncture
• Multivariate analysis ns
• ? Optimal size for TOP placement
• Blom 1.5cm

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Stomal Stenosis

• Surgical Factors
• How the trachea is divided
• Where the stoma is sited
• Laryngectomy tube
• Primary TOP
• Neck dissection
• Pec major
• Post-op wound complications

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Stomal Stenosis

• No association
• No association
• No association (unless stomal infection)

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Stomal Stenosis

• Previous tracheostomy
• Anecdotally highly significant
• Statistically ns

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Stomal Stenosis

• Management
• Wear a stoma button/tube (larytube)

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Stomal Stenosis

• Repeated dilatation

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Stomal Stenosis

• Surgery
• Simple circumferential excision
• CO2 laser
• Multiple radial incisions
• Flaps

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Stomal Stenosis

• Radial incisions

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Stomal Stenosis

• Flaps

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Stomal Stenosis

• Flaps

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Stomal Stenosis

• Flaps

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Stomal Stenosis

• Conclusion
• Less common if a flap is used primarily
• Local wound infection and female sex predispose
• Surgical correction requires new tissue into the
  circumference