Management of Pediatric Tracheocutaneous Fistulae

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BACKGROUND

Tracheocutaneous fistulae (TCF) involve a remnant skin tract that connects the external cervical skin with the anterior trachea following decannulation of a tracheostomy tube (TT). Due to the young age at insertion, length of TT dependence, and propensity for removal with aging, persistent pediatric TCF (PPTCF) is more frequent than in adults. Methods of management are varied, and ideal approaches to management are debated.

BEST PRACTICE

Based on the reviewed literature, patients with PPTCF after decannulation should be evaluated for repair to enhance mucous clearance, reduce the risk of infection, and mitigate social isolation. Endoscopic airway evaluation (both static and dynamic) should be performed prior to repair to determine whether TCF closure is appropriate. Data suggest that patients without evidence of airway obstruction should undergo repair with healing through secondary intention to reduce both complication rates and costs. Patients with large dynamic or static A-frame collapse at the level of the TCF should be considered for single-stage laryngotracheoplasty/laryngotracheal reconstruction with an anterior cap graft. If PPTCF persists following initial repair, further airway assessments should be undertaken with greater attention to levels of obstruction, including consideration of an occluded polysomnogram (Fig. 1). Upon conclusion of the surgery, patients should be returned to spontaneous ventilation and positive pressure minimalized prior to removal of an endotracheal tube. Current evidence is insufficient to power strong conclusions on differences between secondary or primary closure; however, there is a trend toward safety and reduced cost with secondary closure methods.  

Figure 1: Algorithmic representation of best practice for pediatric tracheocutaneous fistulae. (TCF). *Further workup may include occluded polysomnogram or other evaluations for obstruction, endoscopic or otherwise, according to institutional capabilities.