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Avoiding complications with the use of stents for laryngotracheal reconstruction
N MICHAEL FRIEDMAN, MD
Stents and T-tubes each have specific advantages and disadvantages, and all factors must be weighted before deciding which type of stent to use. Generally, stents are easier to use and manage postoperatively, but the patient cannot speak, and constant humidification of the airway is required. Stents must be carefully secured into place to avoid aspiration; 'l-tubes allow for normal speech and airway humidification and are self-securing, but a good deal of familiarity and experience are required to achieve precise cutting and fitting of the device. Aspiration will occur if the T-tube iscephalad to the vocal cords. Placement must be above the reconstruction site and below the vocal cords (Figs I, 2). It is also very important to have knowledgeable nursing staff who understand the mechanics of a T-tube and who know how to properly apply suction both cephalic and caudal to the stoma to avoid mucous plugging and obstruction. When the upper limb of the T-tube gets plugged or when the upper limb hits the undersurface of the cords, complications such as obstruction, loss of speech, and vocal cord trauma occur. If the T-tube lies above the cords, the patient cannot speak and is at risk for aspiration. In trauma patients who require ventilatory assistance, the T-tube has a distinct advantage in that it does not allow for a sealed system. Stents should be used in these patients whenever possible.
From the Department of Otolaryngology and Bronchoesophagology, Rush Medical College of Rush University, and the Head and NeckTreatment Center, Illinois Masonic MedicalCenter, Chicago, IL. Address requests to Michael Friedman, MD, 30 N Michigan Ave, Suite 1107,Chicago, IL 60602. Copyright © 1992 by W.B. Saunders Company 1043-1810/92/0303-0007$05.00/0
206
FIGURE 1. A system for ventilation during the operative procedure with the use of a T-tube. To avoid a leak during surgery when the T-tube is placed in position, a pediatric Foley catheter is placed through the external limb and brought through the proximal aspect of the T-tube. The Foley is inflated. A standard No.7 anesthesia adapter is applied to the external aspect of the T-tube, and the patient is ventilated through the T-tube. Either a Foley catheter can be used or a Xomed Post Pac, which is ideal for occluding the upper limb of the T-tube.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 3, NO 3 (SEP), 1992: PP 206·207
J
FIGURE 2. Precise positioning of the T-tube is essential to avoid complications. (A) Appropriate positioning of the T-tube is shown. The T-tube should be below the level of the vocal cords and above the level of the stenosis. This refers to the upper limb of the T-tube. (B) An incorrectly placed T-tube is shown. The proximal stent of the T-tube is caudad to the stenosis, that is, there is stenosis higher than the upper extent of the T-tube . (C) This sho ws another incorrectly placed T-tube. The T-tube is abutting the undersurface of the vocal cords. The T-tube hits the vocal cords and causes trauma that could lead to scarring and granulation tissue . (D) This is also an improperly placed 'l-tube. The 'f-tube goes above the level of the vocal cords, which may lead to aspiration and aphonia.
ERRATUM
In "Laser Surgery for Laryngeal Cancer" by J. Shapiro, S.M. Zeitels, and M.P. Fried, published in the June 1992 issue of Operative Techniques ill Otolaryngology, an error occurred. On page 89, the fourth sentence should have read as follows: "After assessing the lesion, the suprahyoid epiglottis is retracted posteriorly with Jackson forceps and the incision, using 3 to 5 W at 0.3-mm [not 0.3-p.m] spot size, is initially made in the vallecular mucosa (Fig 10)."
MICHAEL FRIEDMAN
207
Stents and T-tubes each have specific advantages and disadvantages, and all factors must be weighted before deciding which type of stent to use. Generally, stents are easier to use and manage postoperatively, but the patient cannot speak, and constant humidification of the airway is required. Stents must be carefully secured into place to avoid aspiration; 'l-tubes allow for normal speech and airway humidification and are self-securing, but a good deal of familiarity and experience are required to achieve precise cutting and fitting of the device. Aspiration will occur if the T-tube iscephalad to the vocal cords. Placement must be above the reconstruction site and below the vocal cords (Figs I, 2). It is also very important to have knowledgeable nursing staff who understand the mechanics of a T-tube and who know how to properly apply suction both cephalic and caudal to the stoma to avoid mucous plugging and obstruction. When the upper limb of the T-tube gets plugged or when the upper limb hits the undersurface of the cords, complications such as obstruction, loss of speech, and vocal cord trauma occur. If the T-tube lies above the cords, the patient cannot speak and is at risk for aspiration. In trauma patients who require ventilatory assistance, the T-tube has a distinct advantage in that it does not allow for a sealed system. Stents should be used in these patients whenever possible.
From the Department of Otolaryngology and Bronchoesophagology, Rush Medical College of Rush University, and the Head and NeckTreatment Center, Illinois Masonic MedicalCenter, Chicago, IL. Address requests to Michael Friedman, MD, 30 N Michigan Ave, Suite 1107,Chicago, IL 60602. Copyright © 1992 by W.B. Saunders Company 1043-1810/92/0303-0007$05.00/0
206
FIGURE 1. A system for ventilation during the operative procedure with the use of a T-tube. To avoid a leak during surgery when the T-tube is placed in position, a pediatric Foley catheter is placed through the external limb and brought through the proximal aspect of the T-tube. The Foley is inflated. A standard No.7 anesthesia adapter is applied to the external aspect of the T-tube, and the patient is ventilated through the T-tube. Either a Foley catheter can be used or a Xomed Post Pac, which is ideal for occluding the upper limb of the T-tube.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY, VOL 3, NO 3 (SEP), 1992: PP 206·207
J
FIGURE 2. Precise positioning of the T-tube is essential to avoid complications. (A) Appropriate positioning of the T-tube is shown. The T-tube should be below the level of the vocal cords and above the level of the stenosis. This refers to the upper limb of the T-tube. (B) An incorrectly placed T-tube is shown. The proximal stent of the T-tube is caudad to the stenosis, that is, there is stenosis higher than the upper extent of the T-tube . (C) This sho ws another incorrectly placed T-tube. The T-tube is abutting the undersurface of the vocal cords. The T-tube hits the vocal cords and causes trauma that could lead to scarring and granulation tissue . (D) This is also an improperly placed 'l-tube. The 'f-tube goes above the level of the vocal cords, which may lead to aspiration and aphonia.
ERRATUM
In "Laser Surgery for Laryngeal Cancer" by J. Shapiro, S.M. Zeitels, and M.P. Fried, published in the June 1992 issue of Operative Techniques ill Otolaryngology, an error occurred. On page 89, the fourth sentence should have read as follows: "After assessing the lesion, the suprahyoid epiglottis is retracted posteriorly with Jackson forceps and the incision, using 3 to 5 W at 0.3-mm [not 0.3-p.m] spot size, is initially made in the vallecular mucosa (Fig 10)."
MICHAEL FRIEDMAN
207