Correspondence  |   January 2020
Postlaryngectomy Stoma versus Tracheostomy: Comment
Author Notes
  • Wayne State University/Detroit Medical Center, Detroit, Michigan. dgupta@med.wayne.edu
  • (Accepted for publication October 3, 2019.)
    (Accepted for publication October 3, 2019.)×
Article Information
Correspondence
Correspondence   |   January 2020
Postlaryngectomy Stoma versus Tracheostomy: Comment
Anesthesiology 1 2020, Vol.132, 210-211. doi:https://doi.org/10.1097/ALN.0000000000003033
Anesthesiology 1 2020, Vol.132, 210-211. doi:https://doi.org/10.1097/ALN.0000000000003033
Truong and Truong have brought forth some important aspects of general anesthesia using a stoma of a patient after total laryngectomy.1  However, a few simple questions arise. Regarding nil per os status for general anesthesia of a patient after total laryngectomy with a mature stoma, risk of pulmonary aspiration does not cease to exist because as high as 65% of the patients may develop a fistula between pharynx/esophagus and trachea/bronchus or skin around stoma.2,3  Moreover, because there are only a few contraindications to primary or secondary tracheoesophageal puncture with one-way-valve voice prosthesis, tracheoesophageal puncture is performed as the gold standard procedure for voice rehabilitation in 84% of the total laryngectomy patients.4,5  However, the seal of the one-way valve can be imperfect, and aspiration potentially occurs through or around the one-way valve.2  Therefore, for general anesthesia of a patient after total laryngectomy, nil per os is indicated when assuming that a conduit may exist allowing gastric contents to get access to the lungs; preoperative clinical assessment may be unreliable and investigations (videofluoroscopy, fiber-optic endoscopic evaluation of swallowing, manometry, and videomanofluorography) may not be immediately possible to rule out these unwanted conduits.2,3  Assuming that aspiration risk across these unwanted conduits decreases with nil per os, a suitable mask (neonatal/infant size) can be used for short periods of emergent and even elective positive pressure ventilation without intubating stoma. As inspired by the National Tracheostomy Safety Project,6  this is schematically shown in figure 1. Moreover, spontaneous mask breathing through the stoma can ensure optimal preoxygention and ventilation. Of course, the care team must be cautious, and the pressure applied on the mask has to be high enough to ensure adequate mask seal but not too high to cause the compromise of the airway patency of the stoma and/or the segment of the trachea under the mask.