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PART 1: Post-Laryngectomy Stomal Stenosis

What Is a Laryngeal Stoma?

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Causes of Stomal Stenosis

1. Poor Surgical Technique at Creation

• The stoma must be created with adequate tracheal diameter from the start.
• If the trachea is not beveled, the base not elongated, and exposed cartilage not covered with mucosa/skin, the stoma heals with scarring and contracts.
• Cummings notes: "If the stoma is created as described, stomal stenosis is uncommon" - meaning most stenosis is preventable with good surgical technique.

2. Small-Diameter Trachea

• Patients (especially women) with naturally narrower tracheas are at higher risk.
• Women have a higher likelihood of stomal stenosis after laryngectomy.

3. Scar Contracture

• Wound healing after laryngectomy involves fibrosis. If scar tissue forms circumferentially around the stoma, it gradually contracts and narrows the opening.

4. Post-Radiation Changes

• Prior or postoperative radiotherapy causes tissue fibrosis, poor healing, and ischemia. This increases the tendency for scar formation and contraction at the stoma.

5. Wound Infection / Pharyngocutaneous Fistula

• Infection in the postoperative period causes excess granulation tissue and fibrosis.
• A pharyngocutaneous fistula draining near the stoma introduces chronic inflammation, leading to scarring.

6. Cartilage Remnants

• Remnants of thyroid/cricoid cartilage left in the wound can cause inflammatory reactions and scar tissue that narrows the stoma.

7. Stoma Trauma

• Pressure from ill-fitting laryngectomy tubes or prostheses; repeated instrumentation.

8. Tumor Recurrence

• Always must be excluded before treating presumed benign stenosis.

9. Level of Stenosis (Montgomery's Classification)

• Suprastomal - above the stoma (at the tracheal wall just inside)
• Stomal - at the skin-trachea junction itself
• Infrastomal - below (rare in laryngectomy, more common in tracheostomy complications)

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Clinical Features

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Management of Stomal Stenosis

Prevention (Best Approach)

1. Bevel the trachea (cut at an angle to maximize opening)
2. Elongate the base of the stoma (create a longer skin flap inferiorly)
3. Cover all exposed cartilage with skin or mucosa (bare cartilage causes inflammatory stenosis)
4. Use a triangular skin flap ("fish-mouth" technique) especially in irradiated patients

Conservative/Simple Measures

• Laryngectomy tube (stoma button): A silicone or rubber tube placed in the stoma to dilate and maintain the lumen. Required long-term in some cases.
• Regular dilation: Progressively larger stoma buttons used to stretch the narrowed opening.

Surgical Management

a) V-Y Advancement Plasty

• A V-shaped flap of skin around the stoma is advanced to create a larger circular opening.
• The skin tension is redistributed so the stoma remains open.

b) Z-Plasty

• Classic technique to break up linear scar contractures.
• Interdigitating triangular flaps are transposed, reorienting the scar and enlarging the stoma.

c) "Fish-Mouth" Stomoplasty

• The superior or inferior edge of the stoma is incised and a triangular flap of skin is inset into the tracheal wall (like inserting a triangular flap into a cut in the tracheal wall).
• This technique is especially preferred when prior radiotherapy has been given (to break the line of scar contracture).

d) Excision of Cartilage Remnants

• Any residual thyroid or cricoid cartilage fragments contributing to stenosis are removed.
• Preferable to radical excision (which removes too much tissue).

e) Revision Stomaplasty Using Original Technique

• When the stoma was not created correctly initially, the best revision is to redo it using the proper technique (bevel + elongate base + cover cartilage).

f) Prolonged Stoma Tube Use

• In refractory cases, a laryngectomy tube may be worn indefinitely to keep the stoma patent.

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PART 2: Foreign Body in the Bronchus

Introduction

• 25% of cases: the foreign body has been present for over 2 weeks before diagnosis.
• The aspiration may be observed or unobserved - any suspected aspiration must be investigated.

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Types of Foreign Bodies

• Organic FBs (especially peanuts and beans) are particularly dangerous because:
  • Peanuts release oil, causing intense chemical inflammation and granulation tissue.
  • Dried beans absorb water and swell, increasing obstruction.
  • Both cause more tissue reaction and are harder to remove.

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Sites of Lodgement (in Decreasing Frequency)

• More vertical (less angled from the trachea)
• Wider in diameter
• In direct line with the trachea

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Pathophysiology: The Ball-Valve Effect

INSPIRATION:
  Intrathoracic pressure falls → Bronchus widens → Air enters past the FB
                                          ↓
                                   Lung inflates normally

EXPIRATION:
  Intrathoracic pressure rises → Bronchus compresses around the FB
                                          ↓
                               Air CANNOT get out → Lung stays hyperinflated

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Symptoms

By Phase

By Location

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Diagnosis

1. History

• Sudden onset of choking in a child (especially < 4 years)
• History alone may be sufficient to prompt bronchoscopy, even if X-ray is normal.

2. Physical Examination

• Reduced air entry on one side
• Unilateral wheeze
• "Palpable thud" if in trachea (can be felt by placing hand on trachea)

3. Chest X-Ray (AP + Lateral)

4. Inspiratory-Expiratory / Lateral Decubitus Films

• A dependent lung normally collapses in the dependent position.
• If a FB is blocking a bronchus, the dependent lung cannot collapse - it stays hyperinflated.
• This finding is only present in ~50% of patients (specific but not sensitive).

5. CT / Virtual Bronchoscopy

• Highly sensitive for identifying FB location.
• Caveat: If CT requires general anesthesia, most surgeons prefer to proceed directly to rigid bronchoscopy rather than CT first (patient may deteriorate under anesthesia for CT, requiring bronchoscopy anyway).
• CT may be appropriate in asymptomatic patients where diagnosis is uncertain, or after a negative bronchoscopy to look for fragments in subsegmental bronchi.

6. Bronchoscopy (Gold Standard)

• Rigid bronchoscopy is the definitive diagnostic AND therapeutic procedure.

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Management

First Aid / Emergency (if complete obstruction)

• Heimlich maneuver (abdominal thrusts) in children >1 year and adults
• Back blows + chest thrusts in infants <1 year
• If unresponsive: direct laryngoscopy with Magill forceps to remove visible FB

Definitive Management: Rigid Bronchoscopy

Why Rigid, Not Flexible?

• Flexible bronchoscope cannot ventilate the patient and causes significant airway obstruction.
• Rigid bronchoscope allows ventilation (via side holes), better visualization, and more secure FB retrieval.
• Flexible bronchoscopy may be used in older children and adults without GA, but rigid is the mainstay.

Anesthetic Technique

• Spontaneous ventilation with inhalation anesthesia is preferred in children.
  • Reason: Positive pressure ventilation may force FB fragments deeper; paralysed patients have apnoeic periods, making retrieval difficult.
• No paralysis until airway is assessed and secured.
• No endotracheal tube before bronchoscopy (ETT may push a laryngeal/subglottic FB to cause complete obstruction).
• Topical anesthetic (lignocaine) on larynx to prevent laryngospasm.
• Topical adrenaline on mucosa around FB to decongest and reduce bleeding, especially if granulation tissue is present.

Retrieval Technique

• Sharp-edged FBs (pins, needles) are carefully withdrawn INTO the bronchoscope tip before removing to protect the airway mucosa.
• Optical forceps via a Hopkins rod are used to grasp the FB.
• After removal: immediate second look bronchoscopy to ensure no retained fragments.
• Steroids (IV or IM) are given post-procedure to reduce mucosal oedema from airway instrumentation.

Timing of Bronchoscopy

• Urgent if: unstable symptoms, peanut or organic FB, battery, pin, or broken seeds.
• Can be delayed to morning if: child is well with a history of possible FB and stable overnight (remains controversial).

Adjuncts

• A urological stone basket via flexible bronchoscope can be used if rigid bronchoscopy fails.
• Flexible bronchoscopy with urological basket has been reported as a fallback option when rigid fails.

When Endoscopy Fails

• Tracheal fissure (incision into trachea) for tracheal FBs that cannot be retrieved endoscopically.
• Thoracotomy for bronchial FBs that are impacted and cannot be removed endoscopically.

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Complications of Missed or Delayed FB

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Risk of the Procedure Itself

• Reported mortality during endoscopy for FB removal: 0.42-1.8%
• Risk is higher with impacted organic FBs and very young children

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Key Comparison: Stomal Stenosis vs Foreign Body Bronchus

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