DISCUSSION
A tracheocutaneous fistula is commonly regarded as a pathological complication of temporary tracheostomy that results due to failure of spontaneous tracheostome closure post decannulation. Chronic TCF can impair the quality of life, vocalization and the need for local hygiene with frequent hospital visits (1). Although most of these fistulae close spontaneously after decannulation or after local debridement, a significant percentage do not and require some form of surgical closure (2). Despite its clinical impact, there are few studies in the literature on its risk factors and pathogenesis. The incidence of fistula formation is known to be related to the cannulation time. Kulber et al. reported that fistulas do not develop if the cannulation period is less than 16 weeks (3). Incidences of TCF up to 70% have been reported when tracheostomies were maintained for more than 16 weeks (3). In this case, the cannulation time exceeded 2 years. Furthermore, other factors such as previous irradiation of neck, previous tracheostomy and obesity have been suggested to be risk factors for TCF (4). Chronic cough and aspiration could play an important role favoring the onset of TCF, independent of decannulation timing and may also influence the surgical failure and relapse rate. In this case, the patient being a known COPD case, the status of the lung functions was already compromised prior to tracheostomy and the same worsened due to the prolonged cannulation time. A multidisciplinary approach is hence needed for cases like this. TCF closure can be challenging since the laryngeal airway can be suboptimal and abnormal increases in subglottic pressure during the expiration phase can be present (5-7).
In conclusion, TCF presents a challenge to the surgeon as different pathogenic factors affect its formation and healing. A multidisciplinary approach is very much in need for a patient with different medical ailments. Proper patient counselling, duration of cannulation, assessment of risk factors and management of the co-morbidities, all help in determining the incidence and prognosis of tracheocutaneous fistula.
Author Contribution
The author confirms sole responsibility for the following: study conception and design, data collection, analysis and interpretation of results, and manuscript preparation