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