Triangular Stoma Suzuki

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A novel permanent tracheostomy technique for prevention of stomalstenosis (triangular tracheostomy)

Masami Suzuki a, Atsunobu Tsunoda b,*, Satoshi Shirak ura b, Takuro Sumi b,Wataru Nishijima c, Seiji Kishimoto d

a Department of Head & Neck Surgery, Gunma Prefectural Cancer Center, Japanb Department of Otolaryngology, Tokyo Medical and Dental University, Japan

c Department of Head & Neck Surgery, Saitama Cancer Center, Japan

d Department of Head & Neck Surgery, Tokyo Medical and Dental University, Japan

Received 4 November 2009; accepted 18 November 2009

Available online 29 December 2009

Abstract

Objective: Stenosis of a permanent tracheostoma after total laryngectomy lowers postoperative quality of life (QOL), and its prevention is

clinically important.

Methods: From April 2003 to March 2009, the authors performed 87 permanent tracheostomies. For the purpose of prevention of

tracheostomal stenosis, we had applied new technique from October 2005.

Results: The incidence of the tracheostomal stenosis was retrospectively reviewed. Until September 2005, conventional permanent

tracheostomy was applied for 33 cases and tracheostomal stenosis developed in 6 cases (18.2%). On the other hand, stenosis did not

develop in any of the 54 cases in which the new technique was used. The triangular method was significantly superior to the conventional

method in preventing stenosis. Stomal recurrence did not develop in either technique.

Conclusion: The key point of the new technique is as follows: at the upper end of trachea, the posterior part of tracheal cartilage is preserved

and the anterior edge of the tracheostoma is made much lower. The shape of the tracheostoma approximates a triangle, and the area is greaterthan with other methods. From our experience, this technique is safe and effective for the prevention of tracheostomal stenosis.

# 2009 Elsevier Ireland Ltd. All rights reserved.

Keywords: Tracheostomal stenosis; Laryngectomy; Surgical technique

1. Introduction

Stenosis of the permanent tracheostoma after total

laryngectomy lowers postoperative QOL and requires

postoperative stenting and sometimes, reoperation [1–7].

Tracheostomal stenosis is relatively common, with a

reported incidence ranging from 4% to 55% [1–3]. Thefactors influencing this complication are as follows:

excessive scar formation after infection, gender, concomi-

tant neck dissection, stomal recurrence, and an inappropriate

operation. Wax et al. [3] classify permanent tracheostomy

into three techniques: circle, bevel, and plastic. Retro-

spective studies of tracheostomal stenosis in each technique

have reported incidences of 71%, 15%, and 8% [4] and 75%,

33%, and 0%, respectively [3].

As for the plastic technique, Hartwell and Dykes [8],

Trail et al. [9], and Myers and Gallia [10] added an incisionto the posterior wall of the trachea and inserted a skin flap to

widen the aperture of the tracheostoma. Wax et al. [3]

reported another plastic technique in which they incised the

anterior wall of trachea and also inserted a skin flap. Lam

et al. [7] recommended another technique; the skin incision

for the tracheostoma was made inferior to the main skin

incision for the laryngectomy. In these plastic techniques for

tracheostomy, stenosis is relatively uncommon (0–13%) [2–

4,7]. However, in cases in which previous tracheostomy with

www.elsevier.com/locate/anlAuris Nasus Larynx 37 (2010) 465–468

* Corresponding author at: Department of Otolaryngology and Head and

Neck Surgery, Tokyo Medical and Dental University, Bunkyo-ku, Yushima

1-5-45, Tokyo 113-8519, Japan. Tel.: +81 3 5803 5304;

fax: +81 3 3813 2134.

E-mail address: [email protected] (A. Tsunoda).

0385-8146/$ – see front matter # 2009 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.anl.2009.11.007

mailto:[email protected]

http://dx.doi.org/10.1016/j.anl.2009.11.007

http://dx.doi.org/10.1016/j.anl.2009.11.007

mailto:[email protected]



longitudinal skin incision or presternal skin incision was

performed, these plastic techniques were difficult.

We have developed a new technique of permanent

tracheostomy that we call the triangular tracheostomy,

which prevents tracheal stenosis and is not influenced by a

previous tracheostomy or the type of skin incision. In this

study, we retrospectively investigate complications anddiscuss the advantages of our new technique.

2. Surgical technique

The laryngectomy from the trachea is usually made

between the cricoid cartilage and the first tracheal ring

(Fig. 1). If the margin of the tumor is not secured in this

separation, the incision is made much more inferiorly. The

thyroid gland is separated at the isthmus and the unaffected

hemilobe is left attached to the trachea as far as possible.

After pre- and paratracheal neck dissection is completed, the

permanent tracheostomy is then performed:

1. Subcutaneous fat around the tracheostomy is widely

removed.

2. The upper end of trachea is elevated upward with forceps.

The skin over the suprasternal notch is then elevated over

and placed in contact with the anterior surface of the

trachea. The lower margin of the tracheostomy is marked

on the tracheal wall (Fig. 2).

3. Preserving the posterior part of the tracheal cartilage, the

anterior part of the trachea is removed. The unaffected

side of the thyroid gland is left attached to the trachea

(Figs. 1 and 2).4. An inverted suture between the trachea and skin is made

at the lateral and inferior border (Fig. 3).

5. Skin is incised at the level of the inferior border of cricoid

cartilage and sutured with the upper border of the

membranous portion of trachea and posterior half of

the tracheal cartilage. This widens the upper border of the

tracheostomy and the aperture of the triangle shaped

tracheostomy (Fig. 3). The anterior part of the trachea is

incised obliquely and the final shape of the stoma

approximates a rounded triangle (Figs. 1 and 4)

3. Patients and methods

From April 2003 to March 2009, 87 patients who

underwent total laryngectomy at the Gunma Prefectural

Cancer Center and the Saitama Prefectural Cancer Center

were enrolled in this study. The first author performed all the

surgery as a surgeon or trainer. Until September 2005,

conventional permanent tracheostomy with bevel technique

(bevel) was applied in 33 cases (male:female = 29:4, mean

age 63.5 years, range 44–80 years; laryngeal cancer, n = 22;

hypopharyngeal cancer, n = 9; mesopharyngeal cancer,

n = 1; and tracheal cancer, n = 1). After this period, the

above-mentioned new technique (triangular) was applied in

54 cases (male:female = 48:6, mean age 67.1 years, range

49–84 years; laryngeal cancer, n = 25; hypopharyngeal

cancer, n = 25; and mesopharyngeal cancer, n = 4). Stomal

stenosis was defined as follows: (1) requirement for 24-h

stenting, or (2) requirement for surgery to widen the stenosis

within 6 months after the initial permanent tracheostomy.

The following factors were investigated for their influence

on the occurrence of stenosis: stomal recurrence, gender,

concurrent neck dissection, and surgical site infection.

M. Suzuki et al./ Auris Nasus Larynx 37 (2010) 465–468466

Fig. 1. Schematic drawing of the 3 techniques of permanent tracheostomy.

T, thyroid cartilage; C, cricoid cartilage; and I–VI, tracheal rings. Incision

lines through the trachea are red (circle), blue (bevel), and green (triangu-

lar). The point of the triangular technique is that the posterior part of the

tracheal cartilage is preserved. (For interpretation of the references to color

in this figure legend, the reader is referred to the web version of the article.)

Fig. 2. Surgical view of the triangular technique. The posterior edge is

elevatedupward. Note theposterior part of thetracheal ring is preserved and

forms the wide base of an upside-down triangle.

Fig. 3. Postoperative appearance. The stoma has an upside-down triangleshape.



Fisher’s exact probability test was used for statistical

analysis and p < 0.05 was defined as statistically significant.

4. Results

The results are summarized in the Tables 1 and 2. Stomal

recurrence was not observed. The bevel technique was

performed in 33 cases. Six of these showed stomal stenosis

(18.2%) and 2 of these required surgery. Surgical site

infection was seen in seven cases (21%) and concurrent neck

dissection was performed in 20 cases (61.6%), and these

relationships were not statistically significant ( p = 0.09 and

p = 0.21, respectively). One of the 4 female patients

developed stomal stenosis ( p = 0.57) (Table 1).

The triangular technique was applied in 54 patients, 6 of

whom were females 6 (11.1%) and47 (87.0%) hadconcurrent

neck dissection. Surgical site infection after the pharyngeal

fistula, necrosisof thefree-flap, or skin necrosis occurred in 10cases (18.5%). Although these factors are reported to increase

the risk of postoperative stomal stenosis, tracheostomal

stenosis was not encountered in any patients in whom the

triangular technique was used (Table 2). Hence in avoiding

tracheostomal stenosis, the triangular method is significantly

superior to the bevel method. No complaints concerning this

wide stoma were noted from the patients.

5. Discussion

Various factors relating to stomal stenosis are reported,

including stomal recurrence, surgical site infection, and skill

of the surgeon [1–11]. Since women have smaller tracheas

than men, gender is also reported as a factor influencing

stomal stenosis. In the present study, 6 patients showed

stomal stenosis; however, there were no statistically

significant relationships between stomal stenosis and the

above-mentioned factors. Whether or not these factors are

involved, for prevention of postoperative stomal stenosis, the

surgical technique must not only maintain a minimum width

of stenosis but also prevent stomal recurrence.

In our new technique, the posterior part of the lateral wall

of the tracheal cartilage is preserved, so the stoma is not

M. Suzuki et al. / Auris Nasus Larynx 37 (2010) 465–468 467

Fig. 4. Skin preparation for laryngectomy with the triangular technique. The dotted line indicates the anterior margin of the sternocleidomastoid muscle. The

skin marked green is widely removed by the triangular technique, so any skin incision in this area will not interfere with this technique (a). Two years after

permanent tracheostomy formation by the triangular technique (b). H, hyoid bone; C, inferior border of cricoid cartilage; and S, suprasternal notch. (Forinterpretation of the references to color in this figure legend, the reader is referred to the web version of the article.)

Table 1

Factors for stomal stenosis in the patient undergone bevel technique. p:

Fisher’s exact probability test.

Bevel

No stenosis Stenosis

Gender

Male 24 5 N.S.

Female 3 1

Concurrent neck dissection

Done 15 5 N.S.

Not done 12 1

Surgical site infectionPositive 4 3 N.S.

Negative 23 3

Total 27 6

Table 2

Comparison between the bevel and triangular techniques. p: Fisher’s exact

probability test.

No stenosis Stenosis

Bevel 27 6 p = 0.002

Triangular 54 0



round or oval but instead an upside-down triangle (Fig. 3).

Here, we assume the shape of the trachea to be a

combination of semicircle and rectangle: 3 cm in width

and 3 cm in height. The cross-sectional area approximates

8 cm2 which approximates the area of a tracheostoma

formed by the circular technique (Fig. 5A). In the bevel

technique, the length of stoma increases by ffiffiffi

2p

times and the

area increases to 11. 4 cm2 (Fig. 5B). If the base is widened

to 5 cm and an anterior cut made at 6 cm below the upper

edge, the area of the triangle becomes 15 cm2 (Fig. 5C). In

the triangular technique, the anterior part of the trachea is cut

obliquely and the final shape of the stoma approximates a

rounded triangle. Even if the longitudinal length is restricted

to 5 cm, the area of the stoma is 19.6 cm2; 2.5 times as wide

as the original area (Fig. 5D). Although patients undergoing

this technique had various postoperative complications, no

stomal stenosis occurred. The likely reasons for this are the

wider stoma.

A wide tracheostoma is reported to be associated with

problems with postoperative phonation [12]. For patients

who undergo tracheo-esophageal (TE) shunt plasty, anextremely wide tracheostoma may make it difficult for the

patient to close the stoma with a finger. Since we have

never experienced TE shunt, we could not make a specific

comment on this kind of problem. On the other hand, the

TE shunt itself is reported to increase the risk of stomal

stenosis [2]. The triangular technique may therefore

prevent stomal stenosis even when patients undergo TE

shunt plasty.

6. Conclusion

The key points of the triangular technique are preserva-

tion of the posterior part of the tracheal cartilage at the upper

end and a lowered anterior edge of the tracheostoma. The

shape of the stoma approximates a triangle and is wide.

Neither stomal recurrence nor patient discomfort was notedwith this technique. Tracheostomal stenosis was not

encountered despite complications such as surgical site

infection. From our experience, this technique is straightfor-

ward, safe, and particularly effective for prevention of

tracheostomal stenosis.

References

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tracheostomal stenosis. J Jpn Bronchoesophagol Soc 1990;41:47–56

(in Japanese).

[2] Kuo M, Ho CM, Wei WI, Lam KH. Tracheostomal stenosis after totallaryngectomy: an analysis of predisposing clinical factors. Laryngo-

scope 1994;104:59–63.

[3] Wax MK, Touma BJ, Ramadan HH. Tracheostomal stenosis after

laryngectomy: incidence and predisposing factors. Otolaryngol Head

Neck Surg 1995;133:242–7.

[4] Griffith GR, Luce EA. Tracheal stomal stenosis after laryngectomy.

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[5] Loewy WR, Laker HI. Tracheal stoma problems. Arch Otolaryngol

1968;87:477–83.

[6] Balle VH, Bretlau P. Tracheal stoma following total laryngectomy. J

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[7] Lam KH, Wei WI, Wong J, Ong GB. Tracheostome construction

during laryngectomy—a method to prevent stenosis. Laryngoscope

1983;93:212–5.

[8] Hartwell SW, Dykes ER. Construction and care of the end tracheos-tomy. Am J Surg 1967;113:498–500.

[9] Trail M, Chambers R, Leonard J. Z-Plasty of trachealstoma at

laryngectomy. Arch Otolaryngol 1968;88:110–2.

[10] Myers EN, Gallia LJ. Tracheostomal stenosis following total laryn-

gectomy. Ann Otol Rhinol Laryngol 1982;91:450–3.

[11] Vlantis AC, Marres HAM. A surgical technique to prevent tracheos-

tomal stenosis after laryngectomy. Laryngoscope 1998;108:134–7.

[12] Verschuur HP, Gregor RT, HilgersFJM, Balm AJM.The tracheostomain

relation to prosthetic voice rehabilitation. Laryngoscope 1996;106:

111–5.

M. Suzuki et al./ Auris Nasus Larynx 37 (2010) 465–468468

Fig. 5. Difference of the cross-sectional area among tracheostomies: (A)

8.0 cm2 by circular technique; (B) 11.4 cm2 by bevel technique; (C) 15 cm2

by simple triangle; and (D) 19.6 cm2 by the triangular technique. (A)

3 Â 1.5 + 1.125p = 8.0; (B) ffiffiffi

2p

Â A ¼ 11:4; (C) (5 Â 6)/2 = 15; and (D)

(5/2)Â 5 Â p /2 = 19.6.

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Triangular Stoma Suzuki