Tracheocutaneous Sinus following Tracheocutaneous Fistula Repair: Management Strategies in a Pediatric Patient

Abstract

Objective To present a rare case of a pediatric tracheocutaneous sinus years after repair of a tracheocutaneous fistula and to review management strategies. Background A tracheocutaneous fistula is a common sequela of pediatric tracheostomy and can occur in as many as one in three pediatric patients. There is debate in the literature regarding optimal surgical management. Case Presentation An 8-year-old girl presented to the emergency department with swelling and erythema over the anterior neck. Clinical exam and diagnostic imaging revealed an underlying tracheocutaneous sinus. Discussion Complications following pediatric tracheostomy are common and range in complexity from stomal granulation to tracheocutaneous fistula. There is some debate regarding the optimal surgical management of children with tracheocutaneous fistula following tracheostomy. This report discusses the management of a pediatric child with an unusual tracheocutaneous sinus and reviews the various surgical techniques which have been described for definitive repair.

Delayed complication of tracheocutaneous fistula closure with severe compromising subcutaneous emphysema

“…Primary layered closure of a TCF entails removing the TCF tract down to trachea and then closing in 3 or 4 layers: (1)+/− closure of tracheal defect, (2) mobilise and close anterior infrahyoid muscles over the tracheal defect, (3) subcutaneous fat and (4) skin 4 7–9. A small rubber band drain is often placed at the time of closure to reduce the risk of subcutaneous emphysema.…”

“…Often these patients can be monitored in the postanaesthesia care unit and discharged home the same day if stable, or they can be observed overnight on a routine hospital floor 10. Closure by secondary intension has the risk of more scarring with healing as well as formation of a persistent TCF 4…”

“…TCFs have a wide reporting incidence of anywhere from 6% to 55% of paediatric tracheostomy cases and can lead to respiratory infections, chronic cough and difficulty with phonation 2 3. Persistent TCFs are indicated for surgical closure after a 3–6-month period of conservative management 4. We report a rare case of delayed severe subcutaneous emphysema after TCF excision with closure by secondary intention.…”