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Coblation-assisted closure of persistent tracheocutaneous fistulae
International Journal of Pediatric Otorhinolaryngology 85 (2016) 112–114
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Case Report
Coblation-assisted closure of persistent tracheocutaneous fistulae§ David L. Walner a, Chris Mularczyk b,*, Kedar Kakodkar c a b c
Pediatric Otolaryngology, Pediatric Airway Center, Advocate Children’s Hospital, Park Ridge, IL, USA College of Medicine, University of Illinois, Urbana-Champaign, IL, USA Department of Otolaryngology, Community Care Network-St. Catherine, East Chicago, IN, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 January 2016 Received in revised form 17 March 2016 Accepted 18 March 2016 Available online 28 March 2016
Persistent tracheocutaneous fistulae (PTCFs) are sequelae of long-term tracheostomy tube use, and while many procedures exist to correct this issue, several are invasive and incur risk to the patient. This case study discusses a minimally invasive approach to closure of small PFTFs with a coblator device that may reduce the risks associated with other closure procedures. We demonstrated successful tracheocutaneous fistulae closure after coblation in all 4 patients that the operation was performed. We believe this technique can be considered for patients under select circumstances and can be part of a surgeon’s armamentarium for the treatment of small PTCFs. ß 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Tracheotomy Tracheocutaneous fistula
1. Introduction A persistent tracheocutaneous fistula (PTCF) is a sequela that can accompany tracheostomy decannulation in the pediatric population. With an estimated 3.3% [1] to 43% [2] of long-term tracheostomy patients experiencing this complication, several methods of surgical intervention have been developed to correct this issue. Techniques utilized for the closure of PTCFs include excision alone, partial or complete excision with closure, and electrocautery. The methods most discussed in the literature are open methods of PTCF closure that offer a reasonably high success rate accompanied by a greater risk of complication to the patient, require greater recovery time, and necessitate postoperative hospitalization [3,4]. This paper proposes a novel approach to closure of PTCFs in the pediatric population with the use of a coblation device. Coblation is a bipolar method that uses radiofrequency energy to break down soft tissue and has been applied to many otolaryngology procedures including adenoidectomy, tonsillectomy, turbinate reduction, palate reduction, uvulopalatopharyngoplasty, and various head and neck cancer procedures [5,6].
§ Prior publications/submissions: Information from this manuscript was presented as a poster at the 2013 American Society of Pediatric Otolaryngology Spring Meeting (May 16–18, 2014), Las Vegas, Nevada.
E-mail address: [email protected]. * Corresponding author. Tel.: +1 847 674 5585; fax: +1 847 824 7453. E-mail addresses: [email protected] (D.L. Walner), [email protected] (C. Mularczyk). http://dx.doi.org/10.1016/j.ijporl.2016.03.024 0165-5876/ß 2016 Elsevier Ireland Ltd. All rights reserved.
The senior author of this paper (D.L.W.) has performed 4 closures of small PTCF with use of a coblator wand and has seen successful closure in all of these patients. This method allows avoidance of cervical incision, drain placement, and postoperative admission while posing minimal risk. It also allows for reduced operative and anesthetic time. 2. Materials and methods We identified children with small persistent tracheocutaneous fistulae present for more than 6 months after decannulation of their tracheostomy tubes. The dimensions of the fistula in each case were 4 mm or smaller in diameter. All parents signed a consent form to undergo the procedure. We explained preoperatively to the family that it was possible the tracheocutaneous fistula would persist. If so, either the coblation procedure could be considered for a second time or the patient could undergo an open layered surgical closure of the PTCF. The procedure begins with a full microlaryngoscopy and bronchoscopy under general anesthesia in the operating room and the entire airway is checked for any synchronous lesions. If the airway is identified to show significant obstruction and/or pathology then it may be best to avoid closure of the tracheocutaneous fistula at that time. If the airway is assessed and it is felt appropriate for closure of the tracheocutaneous fistula then the procedure ensues. The procedure is most easily performed with 1 person performing endoscopy and positioning a ventilating rigid bronchoscope just above the PTCF within the airway. The assistant then uses the turbinate needle tip coblation wand at a power of 6 and 4. The tip of the wand is placed directly through the tracheal cutaneous fistula. The tip of the wand can be visualized within the airway to ensure
[(Fig._1)TD$IG]
[(Fig._3)TD$IG]
D.L. Walner et al. / International Journal of Pediatric Otorhinolaryngology 85 (2016) 112–114
Fig. 3. Healed PTCF site after coblation assisted closure.
Fig. 1. Bronchoscopic view of needle tip coblator wand visualized within PTCF.
3.2. Patient 2
that it is not touching or coming in contact with the posterior tracheal wall to prevent any injury (Fig. 1). The wand is placed within the fistula and rotated in a clockwise fashion in order to coblate the mucosa circumferentially within the fistula region (Fig. 2). This is performed twice thoroughly to ensure that all mucosa has been coblated. After completion, a sterile Band-Aid with an antibiotic ointment is placed over the PTCF region and the patient is awakened in the operating room. The patients are then discharged home 3 hours later unless significant medical conditions require overnight observation. At home, postoperative management consists of applying an antibiotic ointment twice a day and placing a BandAid over the surgical site for 1 week. Children are able to speak immediately after the procedure and are able to resume normal daily activities within this week period. Patients are told to avoid swimming or submerging in water until their follow-up visit has confirmed a completely healed and closed stoma. The patients come in for two follow-up visits in our office after 2 weeks and 3 months.
A 7-year-old with a long history of medical issues associated with ingesting a button battery several years prior had been tracheostomy tube dependent for several years. The tracheostomy tube has been used without difficulty and the patient had suspected vocal cord paralysis. Over time, vocal cord function improved and the patient’s airway was patent. A sleep study was performed to ensure airway improvement prior to decannulation. A PTCF remained after decannulation that measured 2 mm wide and 4 mm superior to inferior. After coblation of the affected area and subsequent time for healing, it was observed that the patient had successful PTCF closure (Fig. 4) during his 2-week and 3-month postoperative visits. 3.3. Patient 3
3. Results To date, all four patients that have undergone this procedure have had a successful outcome with closure of the persistent tracheocutaneous fistula in a single operation without any complication.
[(Fig._4)TD$IG]
A child with CHARGE syndrome, severe dysphagia, and poor control of secretions at birth underwent a tracheostomy at 1month of age. The patient also underwent choanal atresia repair. The tracheostomy tube was removed at age 10; however, a PTCF remained which measured 2 mm wide by 2 mm superior to
3.1. Patient 1 A 3-year-old presented with a PTCF six months after decannulation. Being born premature, the patient required a tracheostomy within the first few months of life due to chronic lung disease. The child had been stable off of oxygen and therefore was decannulated after consultation with pediatric pulmonology. A PTCF was present measuring 3 mm wide and 3 mm superior to inferior. Due to the small size of the PTCF, coblation was performed. Closure was successful (Fig. 3) and no complications [(Fig._2)TD$IG]were seen during the 2-week and 3-month postoperative visits.
Fig. 2. Coblator wand placed within PTCF.
113
Fig. 4. Healed PTCF site after coblation assisted closure.
114
D.L. Walner et al. / International Journal of Pediatric Otorhinolaryngology 85 (2016) 112–114
inferior. Coblation of PTCF was performed at age 11 and remained closed at the 2-week and 3-month follow-up. 3.4. Patient 4 A 27-week premature baby underwent a tracheostomy at 4months of age. Improved pulmonary status allowed for decannulation at 3-years of age, but a PTCF was present. The patient had successful closure with the use of a coblator device. No complications occurred and the surgical site remained closed at the 2-week and 3-month follow-up with the patient. 4. Discussion A persistent tracheocutaneous fistula is a sequela of long-term tracheotomy that occurs secondary to epithelial growth into the tracheotomy tract, preventing proper closure and healing. Surgical intervention is indicated in PTCFs due to considerable morbidity caused by recurrent aspiration and subsequent respiratory infection, ineffective cough, difficulty in phonation, skin irritation, cosmetic objection, and intolerance to submersion [7]. Several surgical techniques can be used to correct PTCFs including layered primary closure [8], excision and primary closure [9], excision and closure via secondary intention [10], and electrocautery [3]. Primary closure of PTCF is a commonly used technique that may lead to the development of complications. Air expressed by the patient may breach the soft tissue flap and travel into the subcutaneous tissue, thorax, or mediastinum causing subcutaneous emphysema, pneumothorax, or pneumomediastinum [3]. Precautions against these complications include observation for air leakage after closure, drain placement, and postoperative hospitalization [3]. These precautions lead to longer hospital stays and more costly care which may not be appealing to the patient and family. A simple technique using electrocautery for PTCF closure has been described allowing the avoidance of overnight hospital observation, drain placement, and recannulization [3]. The study found that 11 of the 13 patients treated with electrocautery had successful fistulae closure during follow-up. The patients were extubated postoperatively without complication and no patients developed cellulitis or infection at the surgical site [3]. The use of a coblator wand in PTCF closure is a similar method to electrocautery, but may possess additional benefits over electrocautery. Coblation is associated with less postoperative pain than electrocautery in tonsillectomy, and reduced pain may be seen in other coblation procedures such as PTCF closure [11]. While the monopolar electrocautery technique produces temperatures between 400 and 600 degrees Celsius [12], the bipolar coblator wand produces lower operating temperatures of 60 degrees Celsius [13]. Animal studies have shown that lower temperatures of coblation cause significantly less damage to surrounding epithelial tissue and less granulation tissue formation as compared to electrocautery. Use of coblation has also been proposed to reduce healing time compared to electrocautery [12]. We are not aware of studies that make use of other radiofrequency devices for PTCF closure. Coblation is a commonly used device for head and neck procedures and turbinate wands are readily available, which aided in choosing a coblator as the radiofrequency device in the procedure. An additional advantage of coblation over electrocautery is the reduced risk of intraoperative fire and burns. Closure of PTCFs involves working near oxygen rich environments found in the airways of patients, and electrocautery carries risk of igniting a fire. Coblation uses bipolar methods that fail to produce flames in these high oxygen, high fuel environments [14], thus reducing the risk of airway fire. Coblation of PTCF is a quick, low risk procedure that can be performed on an outpatient basis, and may be beneficial to patients
at risk for anesthetic issues or with chronic illness. The procedure can also be considered for healthy patients that want to try a more conservative approach, rather than an open surgery which possesses associated risks such as bleeding, infection, subcutaneous emphysema, or pneumomediastinum. This procedure is recommended for small PTCFs because larger openings may require additional intervention to allow the walls to contact and properly heal together. The coblation procedure may also offer cost savings through reduced operative and anesthetic time, less open equipment necessary for the procedure, as well as avoidance of overnight hospitalization. The subsequent reduction in hospitalization time and an overnight stay is advantageous to both the surgeon and patients as it frees up the surgeon’s time as well as allows patients to be comfortable and return to normal activities quickly after the procedure. 5. Conclusion Coblation-assisted closure of tracheocutaneous fistulae is a novel approach with minimal risk that allows avoidance of a cervical incision, drain placement, and postoperative admission. Successful closure of PTCF has been observed in all patients who underwent the new procedure with no complication. Further use of this technique will provide greater experience and a larger cohort of pediatric patients treated to evaluate its success in a larger patient population. We feel that this procedure can be considered for patients under select circumstances and can be part of a surgeon’s armamentarium for the treatment of small persistent tracheocutaneous fistulae. Financial support No financial support was received. Conflicts of interest None. References [1] P. Oliver, J.R. Richardson, R.W. Club, C.G. Flake, Tracheostomy in children N. Engl. J. Med 267 (1962) 631–637. [2] H.T. Joseph, P. Jani, J.M. Preece, C.M. Bailey, J.N. Evan, Paediatric tracheostomy: persistent tracheocutaneous fistula following decannulation Int. J. Pediatr. Otorhinolaryngol 22 (1991) 231–236. [3] D.A. Eaton, O.E. Brown, D. Parry, Simple technique for tracheocutaneous fistula closure in the pediatric population Ann. Otol. Rhinol. Laryngol 112 (2003) 17–19. [4] T.M. Wine, J.P. Simons, D.K. Mehta, Comparison of 2 techniques of tracheocutaneous fistula closure JAMA Otolaryngol. Head Neck Surg 140 (2014) 237–242. [5] J. Woloszko, C. Gilbride, Coblation technology: plasma-mediated ablation for otolaryngology applications Proc. SPIE 3907 (2000) 306–316. [6] M.S. Timms, S. Ghosh, A. Roper, Adenoidectomy with the coblator: a logical extension of radiofrequency tonsillectomy J. Laryngol. Otol 119 (2005) 398–399. [7] S. Yoram, D.L. Walner, M. Cosenza, R.T. Cotton, Management of persistent tracheocutaneous fistula in the pediatric age group Ann. Otol. Rhinol. Laryngol 108 (1999) 880–883. [8] J.B. Bishop, J. Bostwick, F. Nahai, Persistent tracheostomy stoma Am. J. Surg 140 (1980) 709–710. [9] J.P. Keenan, G.G. Snyder, W.B. Lehmann, J.W. Ruiz, Management of tracheocutaneous fistula Arch. Otolaryngol 104 (1978) 530–531. [10] K.L. Bressler, M.E. Dunham, P.C. Kaiser, L.D. Holinger, Primary closure of persistent tracheocutaneous fistula in children Ann. Otol. Rhinol. Laryngol 103 (1994) 835– 837. [11] R. Glade, S. Pearson, G. Zalzal, S. Choi, Coblation adenotonsillectomy: an improvement over electrocautery technique? Otolaryngol. Head Neck Surg 134 (2006) 852–855. [12] S. Chinpairoj, M.D. Feldman, J.C. Saunders, E.R. Thaler, A comparison of monopolar electrosurgery to a new multipolar electrosurgical system in a rat model Laryngoscope 111 (2001) 213–217. [13] R.H. Temple, M.S. Timms, Paediatric coblation tonsillectomy Int. J. Pediatr. Otorhinolaryngol 61 (2001) 195–198. [14] B.H. Matt, L.A. Cottee, Reducing risk of fire in the operating room using coblation technology Otolaryngol. Head Neck Surg 143 (2010) 454–455.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Case Report
Coblation-assisted closure of persistent tracheocutaneous fistulae§ David L. Walner a, Chris Mularczyk b,*, Kedar Kakodkar c a b c
Pediatric Otolaryngology, Pediatric Airway Center, Advocate Children’s Hospital, Park Ridge, IL, USA College of Medicine, University of Illinois, Urbana-Champaign, IL, USA Department of Otolaryngology, Community Care Network-St. Catherine, East Chicago, IN, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 January 2016 Received in revised form 17 March 2016 Accepted 18 March 2016 Available online 28 March 2016
Persistent tracheocutaneous fistulae (PTCFs) are sequelae of long-term tracheostomy tube use, and while many procedures exist to correct this issue, several are invasive and incur risk to the patient. This case study discusses a minimally invasive approach to closure of small PFTFs with a coblator device that may reduce the risks associated with other closure procedures. We demonstrated successful tracheocutaneous fistulae closure after coblation in all 4 patients that the operation was performed. We believe this technique can be considered for patients under select circumstances and can be part of a surgeon’s armamentarium for the treatment of small PTCFs. ß 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Tracheotomy Tracheocutaneous fistula
1. Introduction A persistent tracheocutaneous fistula (PTCF) is a sequela that can accompany tracheostomy decannulation in the pediatric population. With an estimated 3.3% [1] to 43% [2] of long-term tracheostomy patients experiencing this complication, several methods of surgical intervention have been developed to correct this issue. Techniques utilized for the closure of PTCFs include excision alone, partial or complete excision with closure, and electrocautery. The methods most discussed in the literature are open methods of PTCF closure that offer a reasonably high success rate accompanied by a greater risk of complication to the patient, require greater recovery time, and necessitate postoperative hospitalization [3,4]. This paper proposes a novel approach to closure of PTCFs in the pediatric population with the use of a coblation device. Coblation is a bipolar method that uses radiofrequency energy to break down soft tissue and has been applied to many otolaryngology procedures including adenoidectomy, tonsillectomy, turbinate reduction, palate reduction, uvulopalatopharyngoplasty, and various head and neck cancer procedures [5,6].
§ Prior publications/submissions: Information from this manuscript was presented as a poster at the 2013 American Society of Pediatric Otolaryngology Spring Meeting (May 16–18, 2014), Las Vegas, Nevada.
E-mail address: [email protected]. * Corresponding author. Tel.: +1 847 674 5585; fax: +1 847 824 7453. E-mail addresses: [email protected] (D.L. Walner), [email protected] (C. Mularczyk). http://dx.doi.org/10.1016/j.ijporl.2016.03.024 0165-5876/ß 2016 Elsevier Ireland Ltd. All rights reserved.
The senior author of this paper (D.L.W.) has performed 4 closures of small PTCF with use of a coblator wand and has seen successful closure in all of these patients. This method allows avoidance of cervical incision, drain placement, and postoperative admission while posing minimal risk. It also allows for reduced operative and anesthetic time. 2. Materials and methods We identified children with small persistent tracheocutaneous fistulae present for more than 6 months after decannulation of their tracheostomy tubes. The dimensions of the fistula in each case were 4 mm or smaller in diameter. All parents signed a consent form to undergo the procedure. We explained preoperatively to the family that it was possible the tracheocutaneous fistula would persist. If so, either the coblation procedure could be considered for a second time or the patient could undergo an open layered surgical closure of the PTCF. The procedure begins with a full microlaryngoscopy and bronchoscopy under general anesthesia in the operating room and the entire airway is checked for any synchronous lesions. If the airway is identified to show significant obstruction and/or pathology then it may be best to avoid closure of the tracheocutaneous fistula at that time. If the airway is assessed and it is felt appropriate for closure of the tracheocutaneous fistula then the procedure ensues. The procedure is most easily performed with 1 person performing endoscopy and positioning a ventilating rigid bronchoscope just above the PTCF within the airway. The assistant then uses the turbinate needle tip coblation wand at a power of 6 and 4. The tip of the wand is placed directly through the tracheal cutaneous fistula. The tip of the wand can be visualized within the airway to ensure
[(Fig._1)TD$IG]
[(Fig._3)TD$IG]
D.L. Walner et al. / International Journal of Pediatric Otorhinolaryngology 85 (2016) 112–114
Fig. 3. Healed PTCF site after coblation assisted closure.
Fig. 1. Bronchoscopic view of needle tip coblator wand visualized within PTCF.
3.2. Patient 2
that it is not touching or coming in contact with the posterior tracheal wall to prevent any injury (Fig. 1). The wand is placed within the fistula and rotated in a clockwise fashion in order to coblate the mucosa circumferentially within the fistula region (Fig. 2). This is performed twice thoroughly to ensure that all mucosa has been coblated. After completion, a sterile Band-Aid with an antibiotic ointment is placed over the PTCF region and the patient is awakened in the operating room. The patients are then discharged home 3 hours later unless significant medical conditions require overnight observation. At home, postoperative management consists of applying an antibiotic ointment twice a day and placing a BandAid over the surgical site for 1 week. Children are able to speak immediately after the procedure and are able to resume normal daily activities within this week period. Patients are told to avoid swimming or submerging in water until their follow-up visit has confirmed a completely healed and closed stoma. The patients come in for two follow-up visits in our office after 2 weeks and 3 months.
A 7-year-old with a long history of medical issues associated with ingesting a button battery several years prior had been tracheostomy tube dependent for several years. The tracheostomy tube has been used without difficulty and the patient had suspected vocal cord paralysis. Over time, vocal cord function improved and the patient’s airway was patent. A sleep study was performed to ensure airway improvement prior to decannulation. A PTCF remained after decannulation that measured 2 mm wide and 4 mm superior to inferior. After coblation of the affected area and subsequent time for healing, it was observed that the patient had successful PTCF closure (Fig. 4) during his 2-week and 3-month postoperative visits. 3.3. Patient 3
3. Results To date, all four patients that have undergone this procedure have had a successful outcome with closure of the persistent tracheocutaneous fistula in a single operation without any complication.
[(Fig._4)TD$IG]
A child with CHARGE syndrome, severe dysphagia, and poor control of secretions at birth underwent a tracheostomy at 1month of age. The patient also underwent choanal atresia repair. The tracheostomy tube was removed at age 10; however, a PTCF remained which measured 2 mm wide by 2 mm superior to
3.1. Patient 1 A 3-year-old presented with a PTCF six months after decannulation. Being born premature, the patient required a tracheostomy within the first few months of life due to chronic lung disease. The child had been stable off of oxygen and therefore was decannulated after consultation with pediatric pulmonology. A PTCF was present measuring 3 mm wide and 3 mm superior to inferior. Due to the small size of the PTCF, coblation was performed. Closure was successful (Fig. 3) and no complications [(Fig._2)TD$IG]were seen during the 2-week and 3-month postoperative visits.
Fig. 2. Coblator wand placed within PTCF.
113
Fig. 4. Healed PTCF site after coblation assisted closure.
114
D.L. Walner et al. / International Journal of Pediatric Otorhinolaryngology 85 (2016) 112–114
inferior. Coblation of PTCF was performed at age 11 and remained closed at the 2-week and 3-month follow-up. 3.4. Patient 4 A 27-week premature baby underwent a tracheostomy at 4months of age. Improved pulmonary status allowed for decannulation at 3-years of age, but a PTCF was present. The patient had successful closure with the use of a coblator device. No complications occurred and the surgical site remained closed at the 2-week and 3-month follow-up with the patient. 4. Discussion A persistent tracheocutaneous fistula is a sequela of long-term tracheotomy that occurs secondary to epithelial growth into the tracheotomy tract, preventing proper closure and healing. Surgical intervention is indicated in PTCFs due to considerable morbidity caused by recurrent aspiration and subsequent respiratory infection, ineffective cough, difficulty in phonation, skin irritation, cosmetic objection, and intolerance to submersion [7]. Several surgical techniques can be used to correct PTCFs including layered primary closure [8], excision and primary closure [9], excision and closure via secondary intention [10], and electrocautery [3]. Primary closure of PTCF is a commonly used technique that may lead to the development of complications. Air expressed by the patient may breach the soft tissue flap and travel into the subcutaneous tissue, thorax, or mediastinum causing subcutaneous emphysema, pneumothorax, or pneumomediastinum [3]. Precautions against these complications include observation for air leakage after closure, drain placement, and postoperative hospitalization [3]. These precautions lead to longer hospital stays and more costly care which may not be appealing to the patient and family. A simple technique using electrocautery for PTCF closure has been described allowing the avoidance of overnight hospital observation, drain placement, and recannulization [3]. The study found that 11 of the 13 patients treated with electrocautery had successful fistulae closure during follow-up. The patients were extubated postoperatively without complication and no patients developed cellulitis or infection at the surgical site [3]. The use of a coblator wand in PTCF closure is a similar method to electrocautery, but may possess additional benefits over electrocautery. Coblation is associated with less postoperative pain than electrocautery in tonsillectomy, and reduced pain may be seen in other coblation procedures such as PTCF closure [11]. While the monopolar electrocautery technique produces temperatures between 400 and 600 degrees Celsius [12], the bipolar coblator wand produces lower operating temperatures of 60 degrees Celsius [13]. Animal studies have shown that lower temperatures of coblation cause significantly less damage to surrounding epithelial tissue and less granulation tissue formation as compared to electrocautery. Use of coblation has also been proposed to reduce healing time compared to electrocautery [12]. We are not aware of studies that make use of other radiofrequency devices for PTCF closure. Coblation is a commonly used device for head and neck procedures and turbinate wands are readily available, which aided in choosing a coblator as the radiofrequency device in the procedure. An additional advantage of coblation over electrocautery is the reduced risk of intraoperative fire and burns. Closure of PTCFs involves working near oxygen rich environments found in the airways of patients, and electrocautery carries risk of igniting a fire. Coblation uses bipolar methods that fail to produce flames in these high oxygen, high fuel environments [14], thus reducing the risk of airway fire. Coblation of PTCF is a quick, low risk procedure that can be performed on an outpatient basis, and may be beneficial to patients
at risk for anesthetic issues or with chronic illness. The procedure can also be considered for healthy patients that want to try a more conservative approach, rather than an open surgery which possesses associated risks such as bleeding, infection, subcutaneous emphysema, or pneumomediastinum. This procedure is recommended for small PTCFs because larger openings may require additional intervention to allow the walls to contact and properly heal together. The coblation procedure may also offer cost savings through reduced operative and anesthetic time, less open equipment necessary for the procedure, as well as avoidance of overnight hospitalization. The subsequent reduction in hospitalization time and an overnight stay is advantageous to both the surgeon and patients as it frees up the surgeon’s time as well as allows patients to be comfortable and return to normal activities quickly after the procedure. 5. Conclusion Coblation-assisted closure of tracheocutaneous fistulae is a novel approach with minimal risk that allows avoidance of a cervical incision, drain placement, and postoperative admission. Successful closure of PTCF has been observed in all patients who underwent the new procedure with no complication. Further use of this technique will provide greater experience and a larger cohort of pediatric patients treated to evaluate its success in a larger patient population. We feel that this procedure can be considered for patients under select circumstances and can be part of a surgeon’s armamentarium for the treatment of small persistent tracheocutaneous fistulae. Financial support No financial support was received. Conflicts of interest None. References [1] P. Oliver, J.R. Richardson, R.W. Club, C.G. Flake, Tracheostomy in children N. Engl. J. Med 267 (1962) 631–637. [2] H.T. Joseph, P. Jani, J.M. Preece, C.M. Bailey, J.N. Evan, Paediatric tracheostomy: persistent tracheocutaneous fistula following decannulation Int. J. Pediatr. Otorhinolaryngol 22 (1991) 231–236. [3] D.A. Eaton, O.E. Brown, D. Parry, Simple technique for tracheocutaneous fistula closure in the pediatric population Ann. Otol. Rhinol. Laryngol 112 (2003) 17–19. [4] T.M. Wine, J.P. Simons, D.K. Mehta, Comparison of 2 techniques of tracheocutaneous fistula closure JAMA Otolaryngol. Head Neck Surg 140 (2014) 237–242. [5] J. Woloszko, C. Gilbride, Coblation technology: plasma-mediated ablation for otolaryngology applications Proc. SPIE 3907 (2000) 306–316. [6] M.S. Timms, S. Ghosh, A. Roper, Adenoidectomy with the coblator: a logical extension of radiofrequency tonsillectomy J. Laryngol. Otol 119 (2005) 398–399. [7] S. Yoram, D.L. Walner, M. Cosenza, R.T. Cotton, Management of persistent tracheocutaneous fistula in the pediatric age group Ann. Otol. Rhinol. Laryngol 108 (1999) 880–883. [8] J.B. Bishop, J. Bostwick, F. Nahai, Persistent tracheostomy stoma Am. J. Surg 140 (1980) 709–710. [9] J.P. Keenan, G.G. Snyder, W.B. Lehmann, J.W. Ruiz, Management of tracheocutaneous fistula Arch. Otolaryngol 104 (1978) 530–531. [10] K.L. Bressler, M.E. Dunham, P.C. Kaiser, L.D. Holinger, Primary closure of persistent tracheocutaneous fistula in children Ann. Otol. Rhinol. Laryngol 103 (1994) 835– 837. [11] R. Glade, S. Pearson, G. Zalzal, S. Choi, Coblation adenotonsillectomy: an improvement over electrocautery technique? Otolaryngol. Head Neck Surg 134 (2006) 852–855. [12] S. Chinpairoj, M.D. Feldman, J.C. Saunders, E.R. Thaler, A comparison of monopolar electrosurgery to a new multipolar electrosurgical system in a rat model Laryngoscope 111 (2001) 213–217. [13] R.H. Temple, M.S. Timms, Paediatric coblation tonsillectomy Int. J. Pediatr. Otorhinolaryngol 61 (2001) 195–198. [14] B.H. Matt, L.A. Cottee, Reducing risk of fire in the operating room using coblation technology Otolaryngol. Head Neck Surg 143 (2010) 454–455.