Patients with a postlaryngectomy stoma present important and often unrecognized implications for perioperative airway management. Because of its appearance and location, the stoma (A) is often mistaken for a tracheostomy (B). A tracheostomy is a surgical opening to access the tracheal lumen with the entire larynx remaining intact (D). In contrast, after total laryngectomy, the trachea is brought to the skin as a stoma, which no longer has any anatomical connection with the oropharyngeal cavity and digestive tract (C). Consequently, it is impossible to deliver oxygen to the lungs with nasal cannula, face mask, or bag-mask ventilation. Attempts to intubate the trachea from above the stoma via the oral or nasal route will be unsuccessful. Similarly, because pulmonary aspiration of gastric contents cannot occur, these patients do not need to be kept nil per os for surgery.1 Conversely, the risk of foreign body aspiration is significant because of the direct communication of the stoma with its surroundings.2 Care must be taken when handling small objects such as syringe covers near an uncovered stoma.
To enable intraoperative positive pressure ventilation, it is necessary to insert a cuffed tracheal tube into the stoma. In contrast to the dangers of changing a fresh tracheostomy tube to a tracheal tube,3 tube placement into the laryngectomy stoma is usually straightforward. In patients with a tracheoesophageal voice prosthesis, however, caution should be exercised to prevent its dislodgement into the lungs. Finally, because the distance from the stoma to the carina is relatively short, endobronchial intubation may occur.
The authors acknowledge David M. Aten, M.A., C.M.I., Senior Medical Illustrator, M.D. Anderson Cancer Center, Houston, Texas, for his help in creating the illustrations (C and D) that accompany this article.
The authors declare no competing interests.