Overview
Definition:
Tracheal stomal stenosis refers to the narrowing or obstruction of the stoma (opening) created for a tracheostomy
This complication can occur at the level of the skin, subcutaneous tissue, trachea itself, or a combination thereof, impeding airflow and leading to respiratory distress
It is a common late complication of tracheostomy, necessitating revision or reconstructive surgery for adequate airway patency.
Epidemiology:
The incidence of tracheal stomal stenosis varies significantly, reported from 2% to over 20% in different studies, largely dependent on tracheostomy duration, stoma care, type of tube used, and underlying patient factors
Risk is higher in patients with prolonged tracheostomy, infection, or repeated tube changes.
Clinical Significance:
Significant tracheal stomal stenosis compromises airway patency, leading to dyspnea, stridor, increased work of breathing, and potential respiratory failure
It can necessitate prolonged tracheostomy dependence, impact speech and swallowing, and significantly impair a patient's quality of life
Early recognition and appropriate management are crucial to restore adequate airflow and prevent further morbidity.
Clinical Presentation
Symptoms:
Progressive dyspnea on exertion
Inspiratory stridor, especially upon inspiration through the tracheostomy
Increased difficulty in passing or changing the tracheostomy tube
Persistent secretions or difficulty clearing secretions
Cough and choking spells
Audible noisy breathing
Pain or discomfort around the stoma site.
Signs:
Visible narrowing or induration of the tracheostomy stoma
Granulation tissue formation at the stoma edges
Difficulty in visualizing the tracheal lumen through the stoma
Presence of a small or malformed stoma
Inability to insert a full-sized tracheostomy tube
Wheezing or stridor on auscultation
Signs of respiratory distress such as tachypnea, retractions, and accessory muscle use.
Diagnostic Criteria:
Diagnosis is primarily clinical, confirmed by objective assessment
Key diagnostic indicators include inability to pass a standard tracheostomy tube of appropriate size
visualization of significant narrowing on laryngoscopy or bronchoscopy
and often confirmed by imaging such as CT scan of the neck and chest showing tracheal lumen compromise
Absence of airflow through the tracheostomy tube in a spontaneously breathing patient is a critical sign.
Diagnostic Approach
History Taking:
Detailed history of tracheostomy insertion, duration, type of tube used (cuffed/uncuffed, material), frequency of tube changes, presence of infection, wound healing issues, and previous stoma care
Inquire about progressive breathing difficulties, stridor, and ability to speak or cough effectively
Note any history of radiotherapy to the neck.
Physical Examination:
Careful inspection of the tracheostomy site for signs of inflammation, granulation tissue, scarring, and stomal diameter
Palpation for induration and tenderness
Assessment of respiratory effort, auscultation of breath sounds for stridor or wheezing
Attempt to gently pass a smaller caliber tube or obturator to assess patency
Assess ability to vocalize.
Investigations:
Flexible laryngoscopy or bronchoscopy is the gold standard to visualize the stoma and proximal trachea, assess the degree of stenosis, and identify granulation tissue or scarring
CT scan of the neck with coronal and sagittal reconstructions can effectively delineate the extent and nature of the stenosis, including involvement of cartilaginous structures
Chest X-ray may show signs of airway compromise or lung changes secondary to poor ventilation.
Differential Diagnosis:
Other causes of upper airway obstruction to consider include vocal cord paralysis, tracheomalacia, laryngeal stenosis, tracheal tumors, foreign body aspiration, and extrinsic compression of the trachea
Differentiating between stomal stenosis and more proximal or distal tracheal pathology is crucial for surgical planning.
Management
Initial Management:
Immediate management focuses on securing the airway if compromised
This may involve insertion of a smaller tracheostomy tube, or if severely compromised, emergent cricothyroidotomy or reintubation via oral/nasal route
Humidification and suctioning to manage secretions
Medical management of infection if present.
Medical Management:
Steroid therapy (topical or systemic) may be considered for inflammatory components of stenosis, but is generally less effective for established fibrotic stenosis
Antibiotics for active stomal infection
Mucolytics to aid secretion clearance.
Surgical Management:
Surgical revision is indicated for symptomatic stomal stenosis
Options include: stomal dilation with balloon catheters (less effective for significant stenosis)
Local excision of scar tissue and granulation tissue with primary closure or stenting
Tracheal resection and reconstruction with end-to-end anastomosis for more severe or extensive stenosis, often involving cartilaginous rings
Use of tracheal grafts or flaps may be considered in complex cases
Surgical planning requires precise knowledge of the stenotic segment length and diameter.
Supportive Care:
Post-operative care involves vigilant airway monitoring, humidified oxygen, aggressive secretion management with suctioning, and pain control
Nutritional support is essential, especially if swallowing is affected
Regular stomal care to prevent infection and promote healing
Speech therapy may be required
Antibiotics as prophylaxis or for infection.
Complications
Early Complications:
Bleeding at the stoma site
Infection of the wound
Persistent airway compromise despite initial intervention
Injury to adjacent structures (e.g., recurrent laryngeal nerve, esophagus)
Pneumothorax or pneumomediastinum
Stomal dehiscence.
Late Complications:
Recurrence of stenosis
Tracheal fistula formation (tracheoesophageal or tracheoinnominate artery fistula)
Chronic granulation tissue formation
Impaired cough mechanism
Chronic respiratory symptoms
Dysphagia and aspiration
Scarring and cosmetic deformity.
Prevention Strategies:
Judicious use of tracheostomy, ensuring it is for the shortest duration necessary
Use of appropriate sized and type of tracheostomy tube, avoiding excessive cuff pressure
Regular stomal care to prevent infection and manage secretions
Gentle tube changes, avoiding excessive trauma to the stoma
Prompt recognition and treatment of granulation tissue
Minimizing unnecessary manipulation of the stoma site.
Prognosis
Factors Affecting Prognosis:
The degree and length of stenosis
The amount of cartilaginous involvement
Presence of associated comorbidities
The patient's general health status
The surgeon's experience and the chosen surgical technique
Early diagnosis and intervention generally lead to better outcomes.
Outcomes:
Successful surgical revision can restore airway patency, relieve symptoms, and significantly improve quality of life
Long-term success rates vary depending on the severity of the original stenosis and the complexity of the reconstruction
Recurrence rates can be significant in severe cases
Decannulation is the goal for many patients.
Follow Up:
Long-term follow-up is essential, typically involving regular clinical assessments and periodic laryngoscopy or bronchoscopy to monitor for recurrence
Patients should be educated on signs and symptoms of recurrent stenosis and advised to seek medical attention promptly
Pulmonary rehabilitation may be beneficial.
Key Points
Exam Focus:
Stomal stenosis is a common late complication of tracheostomy
It presents with progressive dyspnea and stridor
Bronchoscopy is the gold standard for diagnosis
Surgical revision is the definitive treatment, ranging from local excision to tracheal resection and reconstruction
Recurrence is a significant concern.
Clinical Pearls:
Always consider stomal stenosis in a patient with new-onset or worsening dyspnea/stridor post-tracheostomy, especially if they have had the tube for a prolonged period
Meticulous stoma care is paramount in prevention
When performing tracheal resection for stenosis, ensure adequate margins and appropriate anastomotic tension.
Common Mistakes:
Delaying diagnosis and intervention, attributing symptoms solely to tracheostomy tube issues
Inadequate assessment of the extent of stenosis pre-operatively
Aggressive stomal dilation without addressing underlying fibrotic or cartilaginous changes
Insufficiently wide excision of scar tissue
Overly aggressive stomal closure leading to recurrent stenosis.