An approach to complex tracheostomal complications.

Fistula formation following laryngectomy, most commonly pharyngocutaneous, is the most feared non-fatal complication with an incidence range from 5 to 30%. Tracheoesophageal fistulae are rare and are, most often, associated with the creation of a surgical speech fistula or the stomal recurrence of a malignant tumour. We present five cases of complex post-laryngectomy fistulae and a new approach to management. We advocate debridement of infected or necrotic tissue, primary suture of the oesophageal and tracheal defects with interposition of healthy viable tissue as a free transfer. If necessary, the trachea can be mobilised and the tracheostome is lowered to healthy tissue outside the radiotherapy field, with excision of the manubrium and hemi-clavicles. This technique allows reconstruction as a single stage procedure and does not preclude the future creation of a further tracheoesophageal fistula for voice rehabilitation.