CASO CLÍNICO

 

An unusual complication of Björk flap in elective tracheotomy

Una complicación inusual del colgajo de Björk en la traqueotomía electiva

 

 

L. Villalaín Álvarez¹, J.C. de Vicente Rodríguez², I. Peña González¹, S. Llorente Pendás¹

¹ Médico Adjunto
² Jefe de Sección
Servicio de Cirugía Oral y Maxilofacial.
Hospital Universitario Central de Asturias. Oviedo, España

Correspondence

 

 

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ABSTRACT

Introduction. Elective temporary tracheotomy in often performed in head and neck oncologic surgery. An inferiorly hinged tracheal flap (Björk flap) provides a secure airway in the inmediate postoperative period.
Clinical case. This patient underwent resection of an oral cancer and subsequent tracheotomy. After deccanulation, a piece of suture was found into the trachea as an incidental discovery. There were no symptoms related to it, and it was not possible to remove it from the anterior tracheal wall by means of endoscopy, so it was left in place.
Discussion. Elective tracheotomy in head and neck resection for malignancy safeguards the airway, but also has complications. It is very important a careful management of the stoma, without regard if a primary or secundary closure of it is chosen.

Key words: Tracheotomy; Tracheal wall flap; Björk flap; Tracheal endoscopy.

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RESUMEN

Introducción. La traqueotomía temporal electiva se emplea con frecuencia en intervenciones realizadas en el territorio cervicofacial. El colgajo de pared traqueal anterior de base inferior (colgajo de Björk) facilita el cambio de cánula en el periodo postoperatorio.
Caso clínico. Paciente intervenido de un cáncer oral al que tras haberse cerrado el traqueostoma se le descubrió de forma casual un hilo de sutura en la luz traqueal. Dada la dificultad de su retirada por vía endoscópica y ausencia de sintomatología, se decidió no retirarlo.
Discusión. La traqueotomía electiva en oncología cervicofacial asegura la vía aérea, pero presenta también complicaciones. Es muy importante un adecuado manejo del traqueostoma, independientemente de que se elija un cierre primario o secundario del mismo.

Palabras clave: Traqueotomía; Colgajo de pared traqueal; Colgajo de Björk; Endoscopia traqueal.

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Introduction

The term "tracheotomy" derives from the Greek terms tracheia arteria, rough or coarse tube, and tomos, section, and it is used to define the operation of cutting an opening into the tracheal lumen. The term "tracheostomy" derives from tracheia arteria and another Greek term, stoma, mouth, and refers to an opening in the tracheal lumen and skin of the anterior neck. Despite these etymologic differences, the two terms generally are used interchangeably in medical literature.

Tracheotomy is a technique known from Classical Antiquity. However, due to the high rate of failures and complications that accompany it, tracheotomy did not enter routine medical practice until the end of the nineteenth century. At the beginning of the twentieth century, Chevalier Jackson made the first concerted effort to standardize tracheotomy indications, instruments, and technique.^1,2

Elective tracheotomy in oncologic interventions on the craniomaxillofacial territory is performed prophylactically when it is expected that situations may arise in the postoperative period that can compromise the patient’s airways, such as edema or hematoma. It is an alternative to prolonged endotracheal intubation to ensure airway patency.^3-6

Of the different steps involved in the tracheotomy technique, the one that varies most is how the anterior tracheal wall is opened, which depends on different authors’ preference.¹ Proposals include horizontal incisions,⁷ resections of a rectangular or circular segment of tracheal wall,^2,8 and creation of tracheal anterior wall flaps based superiorly⁹ or inferiorly. ^10-12 The latter type was used by Björk for the first time in 1960.³

Like any other surgical procedure, tracheotomy is not free of complications and some of them are serious.^1,2,11

 

Clinical case

A 64-year-old male patient was seen in the Oral and Maxillofacial Surgery Department of the Central University Hospital of Asturias for a squamous-cell carcinoma of the lingual edge, oropharyngeal lateral wall, tonsil area, and soft palate on the left side. The patient also had marked metastatic lymph node enlargement along the vascular axes and submaxillary regions on both sides of the neck.

In the first operation, the tumor was resected, left classic radical lymph node dissection was performed, and the defect was reconstructed with an anterolateral microvascularized fasciocutaneous flap from the thigh. Three weeks later, classic right radical lymph node dissection was performed. Given the magnitude of the surgery and the likelihood of postoperative complications, an elective regulated tracheotomy also was practiced in the first operation and a Björk flap was created to cover the tracheal opening. The tracheotomy was maintained until several days after the second intervention. The tracheostoma closed spontaneously after decannulating the patient and releasing the tracheal flap attachment to the skin (Fig. 1).

The patient later received complementary irradiation of the oral cavity, oropharynx, and cervical lymph nodes at levels I to VI.

In control CT scanning of the cervicothoracic area ordered 4 months after surgery, a small mass consistent with a neoplastic process was observed in the right middle lung lobe and the patient was referred to the Pneumology Department. Bronchoscopy detected a black suture in the tracheal lumen, about 2.5 cm long, with one end attached to the tracheal anterior wall (Fig. 2). Removal was attempted, but it was firmly affixed and the decision was made to leave it to avoid potential tearing of the tracheal wall. The pulmonary mass was found eventually to be inflammatory and it resolved spontaneously.

The only symptoms of the tracheal suture referred by the patient were an occasional sensation of foreign body, without producing coughing or dyspnea.

 

Discussion

The indications for tracheotomy include cases of surgery in which possible postoperative complications are foreseeable that may compromise airways.^1,2 Such interventions are fundamentally oncologic surgery involving ablation of a tumor located in the upper airway or digestive tract, generally associated with cervical lymph node dissection. The complications that may affect airways are mainly tissue edema and the development of hematoma.^3,4 The alternative to tracheotomy in these cases is postoperative maintenance of endotracheal intubation. Neither tracheotomy nor prolonged intubation is free of complications. The rate of complications, some of them mortal, associated with tra cheotomy increase when the procedure is performed under emergency conditions, a situation that may arise in the postoperative period of cervicofacial oncologic surgery, as mentioned above. In this sense, efforts must focus on determining before surgery, on the basis of the characteristics of the tumor and patient, what possibility exists that respiratory compromise could occur after surgery, in order to properly select the patients who will undergo elective tracheotomy. ^5,6 Tracheotomy was performed in the case reported here for several reasons. On the one hand, the tumor was extensive, located in an area in which there was a risk of upper airway compromise, and the proposed defect reconstruction was with a microvascularized flap. Consequently, considerable postoperative edema of the oral and oropharyngeal soft tissues was expected. On the other hand, classic radical cervical lymph node dissection was planned, which is associated with a risk of cervical hematoma. Finally, a second cervical dissection was scheduled 3 weeks after the first operation, which would require a new intubation that would be difficult to perform on a recently intervened oropharynx.

The type of tracheal opening chosen was a horizontal incision between the second and third tracheal rings, followed by creation of a tracheal anterior wall flap with an inferior base (Björk flap, hatch, or lower hinge) sutured directly to the skin. We chose this flap because we believe, as other authors do, that it facilitates the change of cannula in the postoperative period, diminishing the risk of creating a false pathway or impeding cannula reintroduction. On the other hand, it seems to be clear that this type of incision, compared with others, produces less tracheal stenosis.^1,3,4,10,11

No consensus exists as to how a tracheostoma should be closed when the patient is decannulated. In order to accelerate the process and avoid the possible consequences of defective healing by second intention (tracheal stenosis, skin retraction, diminished tracheal mobility, establishment of tracheocutaneous fistulas, and disfiguring scars), some authors recommend surgical closure of the tracheotomy by anatomically repositioning the tracheal cartilaginous flap and suturing by planes¹ or, at least, releasing the tracheal flap from neighboring soft tissues.¹³ However, primary closure entails risks, such as the appearance of subcutaneous emphysema, pneumomediastinum, or pneumothorax.¹⁴ Most authors recommend waiting for spontaneous closure by second intention, reserving surgical closure of tracheostomas for cases of long duration in which a tracheocutaneous fistula has formed.^2,3,11,12

The case reported here involved a patient in which a suture in the tracheal lumen was encountered incidentally in the course of bronchoscopy for another purpose. This suture measured approximately 2.5 cm and was attached at one end to the anterior tracheal wall. It is practically certain that it was one of the silk sutures that had affixed the tracheal flap to the skin. We could not explain exactly why it was found in that position. It is likely that when the stitches that affixed the tracheal flap to the skin were removed, a stitch remained inadvertently attached to the tracheal flap when it was released. This flap spontaneously acquired a dorsal position, dragging along with it the suture that had not been removed and the suture knot situated on its external face (Figs. 3A and 3B). This would explain why the suture could not be removed from the tracheal lumen by bronchoscopy.

A similar case has been reported in the literature,¹⁵ in which the suture was removed by laryngeal microsurgery. In this case, the suture was introduced between the vocal cords and the patient perceived a foreign body sensation and suffered intermittent coughing.

In a decision reached with our patient, we decided not to remove the suture because it was subglottal and only originated occasional symptoms of foreign body sensation. Moreover, the patient did not wish to undergo more surgical interventions.

 

Conclusions

The inferiorly based, tracheal anterior wall flap (Björk flap, hatch, or inferior hinge) ensures and facilitates the change of cannula in the postoperative period of patients who undergo an elective temporary tracheotomy.

Proper postoperative management of the tracheostoma is very important, regardless of whether primary or secondary closure is chosen.

 

 

Correspondence:
Lucas Villalaín Álvarez
C. Piloña nº 23 6ºH
33006 Oviedo. España
Email: lvillalain@hotmail.com

Recibido: 12.05.2008
Aceptado: 15.10.2008

 

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