6 Several case reports have described late complications secondary to tracheotomy and prolonged mechanical ventilation, but the detection of a broad tracheocutaneous

fistula located on the cuff of the tracheotomy cannula is a rare event that may lead to severe difficulties in airway management for ventilator-dependent patients. In the literature, it has been reported that the frequency of occurrence of tracheocutaneous fistula ranges from 3.3% to 29%.7 The incidence of fistula formation is closely related to the time of cannulation. Kulber and Passy reported that a fistula does not develop when the duration find more of cannulation is less than 16 weeks, but its incidence increases to 70% when the retention period is 16 weeks or more.8 The presence of a fistula increases the possibility of respiratory tract infections, including repeated aspiration and pneumonia. It also causes difficulties in

phonation, coughing, cosmetic problems, and limitations to daily activities, including swimming and bathing. Therefore, surgical closure is necessary when a fistula GSK1210151A mw occurs, but the management of large tracheocutaneous fistulas is not well described in the otolaryngology literature. Some authors have focused on the excision of the fistula tract with or without the use of a strap muscle or sternocleidomastoid flap.9 Others have proposed staged closures over a period of months to allow secondary healing to occur in order to avoid complications of dehiscence, pneumomediastinum, and infection.10 In the literature, it is difficult to find a report on the surgical closure of a fistula whose

diameter is 1 cm or greater. Only Berenholz et al.9 have reported that a fistula of greater than 1 cm diameter was successfully closed using a muscular flap after a fistulectomy, but there has not been a report on a simple and safe surgical diglyceride closure of a large tracheocutaneous fistula greater than 1 cm diameter.9 In our case report, the diameter of the fistula was approximately 4 cm and its size prevented any possibility of surgical repair or resection of the lesion. In fact a small tracheocutaneous fistula may generally be sutured after fistulectomy or the fistula can be closed using a hinged flap or a bipedicle flap, but these techniques were impossible in our case. Another key feature of this clinical case involved the difficult management of the airways to allow adequate mechanical ventilation. The opening of a tracheocutaneous fistula in the above described location required a tracheotomy very proximal to the tracheal carina. Since the insertion of a cuffed cannula in the trachea was hindered by the reduced size of the residual trachea, a variation on the lung isolation technique was attempted, usually performed on patients undergoing thoracic surgery.