Mediastinal Tracheostomy in the Management of Recurrent Laryngeal Cancer
A 61-year-old man was treated for laryngeal squamous cell cancer with radiation in 2004. He presented again in 2012, with squamous cell cancer on the floor of his mouth. He underwent a right mandibulectomy with a free forearm flap, followed by radiation. A year later, he was found to have recurrent laryngeal cancer and underwent a total laryngectomy. Unfortunately, one of the margins was positive on the final pathology. The patient presented again in 2013 with obstructive symptoms and hemoptysis, synonymous with local recurrence at the tracheostomy level. There was no evidence of distant disease, and, in view of his relative young age and good functional status, he underwent a mediastinal tracheostomy with a right myocutaneous pectoralis flap.
The patient's postoperative course was significant for moderate ischemia of the proximal posterior tracheal wall. This was managed conservatively, with the patient requiring multiple dilations and the temporary placement of a fully covered airway stent, before tolerating a permanent laryngeal tube. Pathological examination showed all the new margins to be negative, and multiple subsequent imaging studies revealed no local recurrence. However, the patient was found to have a suspicious 1 cm left upper nodule for which he underwent a thoracoscopic wedge resection 22 months after his mediastinal tracheostomy. This showed another squamous cell cancer that was less differentiated than his prior oral and laryngeal cancers. The patient is currently disease free, 36 months after his mediastinal tracheostomy.