- Robert H. Maisel
Tracheostomy historically is the first treatment offered for obstructive sleep apnea (OSA). It remains the only surgical option directed at OSA that uniformly eliminates sleep apnea permanently. Since it was first introduced in 1968 and subsequently reported in several large studies, newer choices of medical and surgical intervention have reduced the number of people needing a tracheostomy to relieve severe and life-threatening OSA.
There remain some patients for whom other treatments have been ineffective, intolerable, or refused. Current reports have agreed with the long-term success at maintaining an open upper airway by creating a tracheostomy to reduce morbidity and mortality.
Patient selection and counseling are paramount in long-term, uncomplicated success of tracheostomy for OSA. Education of the patient and family in anticipation of surgery, as well as postsurgical support of the caregivers, is needed. The patient and family frequently attend training in stoma and device care. The confidence and the ability to manage a tracheostomy at home achieved by support and good teaching justify the time and effort of these sessions. The patient must be discharged with a full complement of equipment available and with the knowledge of how to use this in the home environment. Nurse visits are helpful, but the surgeon and his or her staff are the best source to create a confident patient and family in the management of the tracheostomy. Many patients do very well with infrequent office visits and manage self-care with telephone contact and equipment supplies as the only support needed. We recommend an office visit two to four times a year in all circumstances once the stoma care is stable.
For the patient with normal body habitus who has failed mechanical devices and stepwise surgery of the palate and tongue, a routine tracheostomy through a horizontal skin incision created midway between the cricoid cartilage and the sternal notch will result in satisfactory stoma maintenance. Blunt and sharp dissection through the platysmal layer is performed and a vertical dissection at the midline of the strap muscles result in an approach to the cricoid with the thyroid gland immediately below. This endocrine gland is divided and ligated to expose the midline of the trachea, and a window below the second tracheal ring can be removed, as is standard for open tracheostomy. A cuffed double-lumen tube (Shiley #8 in males; Shiley #6 in females) is placed through this fenestra and the faceplate is sutured to the skin. Sutures are left in place 3 to 5 days. Gauze ties of 
inch (6.35 mm) to secure the tube in place are placed around the neck and secured with one or two fingers laxity between the tape and neck skin. Patients with sleep apnea are anticipated to have an active and productive life once the condition has been treated surgically, and even with significant comorbidities, we anticipate an active lifestyle. However, the tracheostomy technique described earlier does not allow temporary extubation and under only extraordinary circumstances would allow a tube-free tracheostomy, even for short times during the day or overnight. Therefore most patients, including many of normal body habitus, who have severe OSA and have been untreatable with mechanical positive pressure or upper airway surgery are recommended to have a tracheostomy as described later. Most of these patients are severely obese with a body mass index greater than 36 and with sizable adipose tissue between the skin and trachea. These people need a more thorough approach to the airway and a better solution to stoma hygiene in what is anticipated as lifelong airway and apnea management.
Complications from routine tracheostomies in this population have included granulation; tracheal stenosis; loss of lumen with accidental extubation; and low-grade chronic wound infection with pain, malodor, bleeding and a weeping wound.
Although tracheostomy for OSA was reported by Kuhlo et al. in 1968, Fee and Ward described a technique of skin-lined flap tracheostomy to overcome the complications noted earlier in the obese patient with OSA. The goal had been to create a permanent stoma with a diameter of 8 to 10 mm.
Their plan was to create a series of vertical and horizontal skin incisions that allow easy access to the fibrofatty pad of tissue overlying the muscles from the level of the hyoid bone above to the sternal notch below ( Fig. 60.1 ). This flap elevation includes defatting the skin flaps safely and creating two vertical and two horizontal skin flaps that will be sutured to the trachea mucosa. Defatting and elevating the skin flaps safely with respect to vitalizing the skin are extremely important. When elevation is complete, the surgical field is ready for a lipectomy, which is achieved from the level of the hyoid bone often down to the level of the fifth tracheal ring ( Fig. 60.2 ). The skin flap elevation allows access to perform a hyoidopexy to the mandible or thyroid cartilage, if indicated, and allows removal of submental fat, which will permit the healed patient to maintain an open tracheal lumen without a submental flap occluding the stoma when the head falls to the chest during sleep.
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