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TRACHEOCUTANEOUS FISTULA

TRACHEOCUTANEOUS FISTULA. Differential Diagnosis. Subcutaneous Emphysema. Differential Diagnosis. Steroid Use. Tracheocutaneous Fistula. Incidence Pathophysiology Treatment Complications Anesthetic Implication. Incidence. 3.3 - 42% in pediatric patients

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TRACHEOCUTANEOUS FISTULA

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  1. TRACHEOCUTANEOUS FISTULA

  2. Differential Diagnosis Subcutaneous Emphysema

  3. Differential Diagnosis Steroid Use

  4. Tracheocutaneous Fistula • Incidence • Pathophysiology • Treatment • Complications • Anesthetic Implication

  5. Incidence • 3.3 - 42% in pediatric patients • Increases with duration of cannulation • Surgeon dependent • Closure type dependent: • Cauterization and healing by secondary intention • Simple tract excision and closure • Strap muscle flap • Modified layered closure with drain placement

  6. Closure Type • Healing by secondary intention: • Fewer complications • Poor cosmetic appearance • High likelihood of recurrence • Surgical closure: • Smaller scar • Multilayer closure – Fewer complications • Strap muscle flap provides better seal • Drains provide route for air escape

  7. Pathophysiology • Epithelialization of tract • Chronic infection • Granulomatous disease • Prior radiation treatment • Distal obstruction: • Bilateral vocal cord paralysis • Tracheostenosis

  8. Treatment • Examination – laryngoscopy and tracheoscopy • If fistula >= 4 mm, use smaller tracheotomy tube • Plug tracheotomy tube 24 - 72 hours • Tape tracheotomy site • If fistula < 4 mm, surgical repair of fistula

  9. Possible complications • Subcutaneous emphysema • Pneumomediastinum • Pneumothorax • Respiratory compromise

  10. Anesthetic Implications • Avoid force and trauma: • Reduced coughing: • Laryngoscopy • Tube insertion • During anesthesia • LTA, narcotics • Awake extubation • Avoid positive pressure • Recommend drain insertion • Monitor 24 hours

  11. References • Drezner DA, Cantrell H. Surgical Management of Tracheocutaneous fistula. Ear, Nose & Throat Journal Jul98; 77(7):534-7. • Keenan JP, Snyder GG et al. Management of Tracheocutaneous Fistula. Arch Otolaryngol SEP78; 104(9):530-1. • Licameli, GR, Marsh BR, Tunkel DE. A Simple Method for Closure of Tracheocutaneous Fistula in Children. Arch Otolryngol. Head Neck Surg Oct97; 123:1066-8. • Mohan VK, Kashyap L et al. Life Threatening Subcutaneous Emphysema Following surgical Repair of Tracheocutaneous Fistula. Paediatric Anaesthesia 2003; 13:339-341. • Wheeler WB, Kurachek SC et al. Respiratory Complications of Tracheocutaneous Fistula Closure. Critical Care Medicine APR91; 19(4):580-2. • White AK, Smitheringale AJ. Treatment of Tracheocutaneous Fistulae in Children. J Otolaryngol FEB98; 18(1):49-52. • Wiel E, Fayoux P et al. Complications of Surgical Closure of Tracheocutaneous Fistula in Pediatric Patients – Two Case Reports. Int. Jour. of Pediatric Otorhinolaryngology 2000; 52:97-9.

  12. Thank You • Dr. Khalil • Dr. Ghelber

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