ABSTRACT
Custom tracheotomy may be required for OSA patients who have abnormal skin to trachea dimension or who have a complication from a standard tracheotomy tube. Custom tubes are often required for the patient with unsuccessful lipectomy or when other surgical treatment to alteration of the neck anatomy is ineffective or not indicated. The tube is custom ordered by taking two measurements of a stable tracheotomy tract. The first measurement is the skin to trachea distance; the second is the overall length of tracheotomy tube. Ill-fitting standard tracheotomy tubes can injure the tracheal wall and produce granulation tissue at the distal opening. This condition is the result of the rigid nature of the tube and chronic irritation of the distal end against the tracheal mucosa. Treatment requires tube removal and bypassing the injured site with a flexible or custom tracheotomy tube. Granulation tissue can also form at the fenestration site when the hole is not centered in the trachea lumen. This can lead to obstruction of the fenestration and the loss of phonation. An accurate measurement of these distances is important for proper fit. We have found the flexible nasal endoscope to be a valuable tool in taking curvilinear measurements and for follow-up evaluation of proper fit. The first measurement is the skin to trachea distance that represents the ‘‘proximal fenestration margin’’. The flexible endoscope is inserted into the tracheotomy tract. As the tip of the scope reaches the trachea this distance is marked by finger position on the scope at the stoma-skin junction as shown in Fig. 5. The proximal fenestration distance is this measurement and an additional 3-4mm, which is added for tracheotomy flange displacement out of the stoma. If the tracheotomy tube flange holds the tube out farther, this distance should be measured and added to the fenestration measurement and shaft measurement. Once the custom tube has been inserted the scope is used within the tube to verify that the fenestration and shaft length are accurate. Most OSA patients usually maintain the same measurements over time, but should be rechecked with the flexible scope before ordering additional tubes. The second measurement or ‘‘shaft length’’ uses the same technique in measuring the site for the distal opening. When replacing an illfitting tube producing a tracheal injury, the scope is extended through the open
Figure 5 Flexible endoscope technique for accurate measurement of tracheotomy tube fenestration and overall tube length.
