We read with interest the Letter to the Editor by Dr. Gupta concerning our article Postlaryngectomy Stoma versus Tracheostomy: Implications for Perioperative Airway Management.1 First, it is important to emphasize that the focus of our image and its teaching points centers on patients with a total laryngectomy stoma without additional pathologies causing a communication between airway and digestive tract. 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. Our discussion does not apply to patients with a partial laryngectomy nor to patients with a tracheoesophageal fistula.
The statement “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 the stoma” is not supported by the quoted references. According to reference 2, the reported incidence of fistulas varies from 5 to 65%. By intentionally hiding the fact that the incidence of fistulas can be as low as 5%, the true incidence of fistulas is grossly distorted. Furthermore, different types of fistulas do not pose the same risks for aspiration. In patients with pharyngocutaneous fistulas, the most common type, aspiration of food is highly unlikely. Food in the pharyngeal cavity would have to exit through a fistula to the skin, and find its way to the laryngectomy stoma for pulmonary aspiration to occur. Similarly, reference 3 clearly states that “aspiration is a very common complication after partial laryngeal resection” and does not provide evidence to support the statement about the risk of aspiration in patients with a total laryngectomy stoma. In contrast to total laryngectomy, which is the topic of our publication, after partial laryngectomy, there still exists a communication between the airway and the digestive tract.
In conclusion, it is apparent that Dr. Gupta fails to clearly distinguish the drastically different risks of pulmonary aspiration in two distinct clinical settings: patients after partial versus total laryngectomy and similarly in patients with pharyngocutaneous versus tracheoesophageal fistulas.
We greatly appreciate the opportunity to respond to this letter.
The authors declare no competing interests.