Research

Original Investigation

Comparison of 2 Techniques of Tracheocutaneous

Fistula Closure
Analysis of Outcomes and Health Care Use
Todd M. Wine, MD; Jeffrey P. Simons, MD; Deepak K. Mehta, MD

IMPORTANCE Tracheocutaneous fistula (TCF) can be repaired using various techniques. This
research is an outcomes and health care use comparative analysis of 2 commonly used
techniques to repair TCF.

OBJECTIVES To compare outcomes and health care use for 2 techniques of TCF repair.

DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study at a tertiary care children’s
hospital. The study population comprised 50 consecutive patients aged 11 to 216 months who
underwent surgical treatment for persistent TCF between January 2007 and August 2012.

INTERVENTIONS Tracheocutaneous fistula closure was achieved using excision of the TCF
alone and healing by secondary intent or excision of the TCF plus primary closure over a drain.

MAIN OUTCOMES AND MEASURES Differences in perioperative and postoperative outcomes.

RESULTS In total, 30 patients underwent excision of a TCF plus primary closure over a drain
(closure group), and 20 patients underwent excision of a TCF alone and healing by secondary
intent (excision group). Statistically, the closure and excision groups were not significantly
different regarding gestational age, age at tracheotomy, duration between decannulation and
TCF repair, and duration of tracheostomy. The mean (SD) procedure durations were 9.7 (3.7)
minutes for the excision group and 37.4 (25.1) minutes for the closure group (P < .001). The
mean (SD) lengths of hospital stay were 0.3 (0.5) day for the excision group and 1.1 (0.9) days
for the closure group (P = .001). The mean (SD) lengths of intensive care unit stay were 0.0
(0.0) day for the excision group and 1.0 (1.5) day for the closure group (P = .001). Closure
success rates were 20 of 22 for the excision group and 30 of 30 for the closure group
(P = .17). Complication rates were 0 of 22 for the excision group and 2 of 30 for the closure
group (P = .50).

CONCLUSIONS AND RELEVANCE The rates of success and complications were not significantly
different between TCF closure and excision groups. Excision of a TCF alone with healing by
secondary intent requires less operating room time and shorter hospital stay, which may
suggest more efficient health care use. Author Affiliations: Department of
Otolaryngology, University of
Colorado School of Medicine, Aurora
(Wine); Department of Pediatric
Otolaryngology, Children’s Hospital of
Colorado, Aurora (Wine); Department
of Otolaryngology, University of
Pittsburgh School of Medicine,
Pittsburgh, Pennsylvania (Simons,
Mehta); Division of Pediatric
Otolaryngology, Children’s Hospital of
Pittsburgh of University of Pittsburgh
Medical Center, Pittsburgh,
Pennsylvania (Simons, Mehta).
Corresponding Author: Todd M.
Wine, MD, Department of Pediatric
Otolaryngology, Children’s Hospital of
Colorado, 13123 E 16th Ave, PO Box
JAMA Otolaryngol Head Neck Surg. 2014;140(3):237-242. doi:10.1001/jamaoto.2013.6521 455, Aurora, CO 80045 (todd.wine
Published online January 30, 2014. @childrenscolorado.org).

237

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 Research Original Investigation
T
racheocutaneous fistula (TCF) can complicate trache-
ostomy decannulation in up to one-third of pediatric
patients.1-4 Historically, the development of TCF was
uncommon, with rates ranging from less than 1% to just
over 3% in 2 large studies5,6 in the 1960s and 1970s. Since
that time, the most common indication for tracheotomy has
changed from acute infections of the upper respiratory tract
to chronic diseases, including congenital malformation, pro-
longed respiratory failure, and neuromuscular disease.4,7
This change in indication for tracheostomy has been associ-
ated with an increase in the duration of tracheostomy,
which has been associated with higher rates of persistent
TCF.3,4,7
Tracheocutaneous fistula occurs secondary to persistent
squamous epithelialization of the tracheostomy stoma tract.
It can be associated with numerous problems, including un-
sightly cosmesis and recurrent skin irritation because of drain-
ing secretions, weak cough and decreased airway protection
due to a loss of subglottic pressure, and continued inability to
enjoy activities such as swimming. The presence of a TCF can
be disheartening to any family who has been elated to finally
achieve decannulation, only to realize that one more prob-
lem needs to be remedied.
The optimal technique used to treat TCF has been de-
bated in the literature and varies among different pediatric
hospitals.1,8-12 This study represents a comparative analysis of
2 different interventions for persistent TCF performed at the
same institution. Our experimental hypothesis was that TCF
excision alone and healing by secondary intent would have
equivalent success rates and decreased complication rates com-
pared with formal TCF closure. Furthermore, we hypoth-
esized that TCF excision alone confers better use of health care
resources.
Methods
This research was approved by the University of Pittsburgh In-
stitutional Review Board as an expedited research project. A
retrospective cohort study was performed identifying all pa-
tients who underwent surgical treatment for TCF between
January 2007 and August 2012 at the Children’s Hospital of
Pittsburgh of University of Pittsburgh Medical Center. Cur-
rent Procedural Technology codes (31820, 31825, and 31830) and
International Classification of Diseases, Ninth Revision, diag-
nosis codes (530.84 and 519.09) and procedure codes (31.72,
31.73, and 31.79) from same-day surgery and hospital admis-
sion records for this time frame were searched to identify pa-
tients. Inclusion criteria were patients undergoing surgical re-
pair of a TCF. Patients were excluded if full review of the
medical record revealed that TCF repair was not performed or
if no follow-up data were available. Recorded were age at tra-
cheotomy, duration between decannulation and TCF repair,
type of surgery, procedure duration and length of hospital stay,
medical comorbidities, success of surgery, polysomnography
data, and complications. The data were uploaded into a spread-
sheet using deidentified information for subsequent statisti-
cal analysis.
238 JAMA Otolaryngology–Head & Neck Surgery March 2014 Volume 140, Number 3
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Two Techniques of Tracheocutaneous Fistula Closure
The patients were stratified into 2 different groups based
on the technique used to close the TCF. The technique used
to repair each TCF was determined primarily by each sur-
geon’s preferred technique. Operatively, all patients under-
went direct laryngoscopy and rigid bronchoscopy to evaluate
for airway obstruction as a cause of the persistent TCF. Dur-
ing the TCF repair, the airway was managed with a cuffed en-
dotracheal tube, and the oxygen percentage was kept at 30%
or lower.
The closure group consisted of patients who underwent
TCF excision with reapproximation of soft tissues and skin and
placement of a passive drain. The trachea was not closed; there-
fore, a drain was critical to prevent subcutaneous emphy-
sema. This procedure involved an elliptical excision around
the tracheostomy stoma and dissection of the fistulous tract
to the level of the trachea. Local muscle and skin flaps were
elevated and reapproximated using absorbable sutures, leav-
ing a small opening around a passive drain. Gauze and tape
were loosely applied. The patient was extubated during sur-
gery and transferred to the pediatric intensive care unit (PICU)
for further monitoring. If no complications were observed over-
night, the patient was discharged the following morning.
The excision group underwent excision of the cutaneous
stoma and tract to the level of the trachea. No attempts were
made to create skin or muscle flaps. The plane of anesthesia
was decreased, and once spontaneous ventilation was pres-
ent, a small, uncuffed tracheostomy tube was reinserted. The
patient was transferred to the postanesthesia care unit (PACU).
Once the patient was fully awake, the tracheostomy tube was
removed, and a dressing of paper tape and gauze was loosely
applied. The patient was observed in phase 1 and phase 2 of
the PACU and then discharged home or admitted to a routine
hospital floor for overnight observation.
The mean values between the closure and excision groups
were compared using 2-tailed t test, and P < .05 was consid-
ered statistically significant. Health care use was assessed by
procedure duration, length of hospital stay, and length of in-
tensive care unit (ICU) stay. Statistical calculations were per-
formed using commercial software (GraphPad QuickCalcs;
GraphPad Software, Inc).
Using current values for charges and costs at our hospi-
tal, the closure and excision groups were compared on a cost
basis. The operating room and anesthesia charges and costs
represent values related to the TCF operation only and do not
include surgeon and anesthesiologist fees or fees related to
other procedures, including direct laryngoscopy and rigid bron-
choscopy. The PACU costs were estimated based on the mean
durations of phase 1 and phase 2 observation. Observation in
the hospital was estimated based on 1 day of observation in
the PICU or on a routine floor.
Results
The initial list of participants included 126 patients. Review of
the medical records revealed numerous patients in our search
who did not have a TCF or did not have surgical treatment for
a TCF. Some others were excluded because they were dupli-
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 Two Techniques of Tracheocutaneous Fistula Closure
Table 1. Comparison of the Tracheocutaneous Fistula (TCF) Excision and Closure Groups
Mean (SD)
Variable Excision Group
Gestational age, wk 35.0 (5.9)
Age at tracheotomy, mo 30.0 (54.8)
Duration of tracheotomy, mo 46.0 (58.7)
Age at TCF repair, mo 77.8 (64.2)
Duration between decannulation and TCF repair, mo 3.5 (3.8)
cations. The remainder was a total of 50 patients (age range,
11-216 months) who underwent treatment for a persistent TCF
after decannulation. In total, 30 patients underwent excision
of a TCF plus primary closure over a drain (closure group), and
20 patients underwent excision of a TCF alone and healing by
secondary intent (excision group). Statistically, the closure and
excision groups were not significantly different regarding ges-
tational age, age at tracheotomy and TCF repair, and duration
of tracheostomy (Table 1). The mean (SD) durations between
decannulation and TCF repair were 3.5 (3.8) months for the ex-
cision group and 10.1 (8.2) months for the closure group
(P = .002). The procedure duration could be calculated for 10
of 22 patients (2 patients underwent revision TCF excision) in
the excision group and for 15 of 30 patients in the closure group.
Discrete procedure durations were unavailable for the other
27 procedures. The mean (SD) procedure durations were 9.7
(3.7) minutes for the excision group and 37.4 (25.1) minutes for
the closure group (P < .001). Three patients in the closure group
had procedure durations exceeding 75 minutes; excluding
them, the mean (SD) procedure duration for the closure group
was 26.0 (9.0) minutes, which was still significantly greater than
the 9.7 (3.7) minutes for the excision group (P < .001).
Closure success rates were 20 of 22 for the excision group
and 30 of 30 for the closure group (P = .17). Complication rates
were 0 of 22 for the excision group and 2 of 30 for the closure
group (P = .50). The complications were progressive subcuta-
neous emphysema requiring intubation (n = 1) and respira-
tory distress of unknown origin requiring intubation (n = 1).
The progressive emphysema (due to persistent agitation and
coughing) occurred despite the presence of the drain and phar-
macologic anxiolysis. The wound was not opened at the bed-
side, and the patient was intubated with a cuffed endotra-
cheal tube to prevent further exacerbation of the subcutaneous
emphysema.
Length of stay evaluation determined health care use. The
mean (SD) lengths of hospital stay were 0.3 (0.5) day for the
excision group and 1.1 (0.9) days for the closure group (P = .001).
The mean (SD) lengths of ICU stay were 0.0 (0.0) day for the
excision group and 1.0 (1.5) day for the closure group (P = .001).
Using current hospital charges and estimates of costs of op-
erating room time and anesthesia, the procedures were com-
pared, incorporating the mean values for procedure dura-
tion. The PACU costs were estimated based on 1.0 hour of phase
1 and 1.9 hours of phase 2 observation, which were the mean
values from our data. Observation in the hospital was calcu-
lated based on 1 day in the PICU or on a routine floor (charges
and estimated costs are listed in Table 2 and Table 3, respec-
tively). The operating room and anesthesia charges and costs
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Original Investigation Research
Closure Group P Valuea
34.0 (5.8) .88
11.0 (17.5) .08
35.1 (20.8) .37
56.2 (27.4) .11
10.1 (8.2) .002 a
Using 2-tailed t test.
represent values related to the TCF operation only and do not
include surgeon and anesthesiologist fees or fees related to
other procedures, including direct laryngoscopy and rigid bron-
choscopy. Using procedure duration, length of stay, and esti-
mates for operating room and length of hospital stay costs, ex-
cision with same-day discharge costs 4-fold less than closure
with PICU admission at our institution (Table 3). Observation
on a routine hospital floor (no ICU care) after closure of a TCF
is 2-fold more costly than excision of the TCF with same-day
discharge alone.
Discussion
Transcutaneous fistula is a known complication of tracheos-
tomy that seems to have increased over time secondary to the
changing indications for and duration of tracheostomy tube
use.3,4,7 As TCF has become more frequent, the medical lit-
erature has increasingly discussed different techniques of clo-
sure. Various procedures to close a TCF include excision of the
TCF alone, partial excision of the TCF with closure, and full
excision of the TCF with closure.9-13 Ultimately, each tech-
nique has been successful at achieving closure of the fistu-
lous tract and has been associated with a low rate of compli-
cations. Transcutaneous fistula excision has the advantage of
increased safety.8 Transcutaneous fistula closure has poten-
tial benefits, including superior cosmesis, decreased healing
time, and possibly less need for revision.
Before repairing any fistula in the body, it is important to
recognize and account for the likely causes of the fistula (for-
eign body, irradiation, inflammation or infection, epitheliali-
zation, neoplasm, and obstruction). In the case of pediatric TCF,
the most likely causes are related to epithelialization, inflam-
mation or infection, and obstruction. Bronchoscopy immedi-
ately before TCF repair was useful to ensure the absence of air-
way obstruction, which could lead not only to failed surgery
but also to airway compromise. Although not directly stud-
ied in this research, bronchoscopy may change management
of TCFs by postponing TCF repair when obstruction is identi-
fied. In our study, successful closure was ultimately achieved
in all 20 patients in the excision group and in all 30 patients in
the closure group. Two patients in the excision group whose
surgery failed initially underwent revision excision, with sub-
sequent success. The reason for their failure is unknown, but
it could have been technical error with persistent skin tract or
infection because bronchoscopies at the first and revision re-
pairs did not identify an airway lesion to explain the persis-
tent fistula.
JAMA Otolaryngology–Head & Neck Surgery March 2014 Volume 140, Number 3 239
 Research Original Investigation Two Techniques of Tracheocutaneous Fistula Closure

Table 2. Charges Related to Tracheocutaneous Fistula Repair Technique

and Postoperative Admission Practicesa

Excision Group, $ Closure Group, $

Variable SDS Floor Floor PICU
Operating room charge 175 175 757 757
Anesthesia 244 244 1057 1057
Abbreviations: PACU, postanesthesia
PACU 1 1641 1641 1641 0
care unit; PICU, pediatric intensive
PACU 2 1609 0 0 0 care unit; SDS, same-day surgery.
Floor 0 2270 2270 0 a
Charges in dollars exclude fees to
PICU 0 0 0 9162 surgeon and anesthesiologist, as
well as fees for direct laryngoscopy
Total 3669 4330 5725 10 976
and rigid bronchoscopy.

Table 3. Estimated Costs Related to Tracheocutaneous Fistula Repair (TCF) Technique

and Postoperative Admission Practicesa

Excision Group, $ Closure Group, $

Variable SDS Floor Floor PICU
Operating room charge 60 60 262 262
Anesthesia 79 79 344 344
PACU 1 535 535 535 0 Abbreviations: See Table 2.
a
PACU 2 524 0 0 0 Cost in dollars excludes fees to
surgeon and anesthesiologist, as
Floor 0 1296 1296 0
well as fees for direct laryngoscopy
PICU 0 0 0 4526 and rigid bronchoscopy. Cost factor
Total 1198 1970 2437 5132 is the ratio of TCF closure with PICU
admission to each of the previous
Cost factor 1.0 1.6 2.0 4.3
columns.

Our study revealed complications subsequent to 0 of 22
procedures in the excision group and 2 of 30 procedures in the
closure group (P = .50), a difference that is not statistically sig-
nificant and concurs with the literature.1,9,11,14 However, when
comparing complication rates, the severity of the complica-
tions must be considered. The 2 complications that occurred
were serious and required endotracheal tube intubation and
prolonged hospitalization. A review of the literature high-
lights that subcutaneous emphysema, pneumomediasti-
num, pneumothorax, and respiratory distress may compli-
cate TCF closure.9-11,14-16 While subcutaneous emphysema has
been reported after TCF excision (in 1 case of 170),14 progres-
sion to pneumothorax and severe respiratory distress have not
been reported, offering credence to the conclusion by White
and Smitheringale8 that TCF excision alone and healing by sec-
ondary intent may be safer.
Although no significant between-group differences were
observed in closure success rates or complication rates in our
study, other significant differences exist. The duration be-
tween decannulation and TCF repair, procedure duration, and
length of stay after the procedure significantly differed be-
tween the closure and excision groups.
Patients can be considered for TCF repair as early as 3
months after decannulation but more typically undergo re-
pair 6 to 14 months after decannulation.8,9,14,17 On average, the
excision cohort underwent surgical repair much earlier (3.5
months) than the closure cohort (10.1 months). This variance
between the cohorts jeopardizes comparison between the 2
groups, but we believe the overall comparison to still be valu-
able. First, each surgeon performing a TCF repair used his or
her preferred technique (46 of 50 TCF repairs) regardless of TCF
duration. The 4 exceptions were TCF closures performed by a
surgeon who typically performs TCF excision. Because these
cases had TCF durations of 2, 2, 5, and 11 months, it seems un-
likely that closure was chosen specifically owing to TCF du-
ration. Furthermore, duration of TCF ranged from approxi-
mately 1.5 to 17 months in the excision group and 2 to 33 months
in the closure group, suggesting that surgeons still chose TCF
closure even when the fistula was present for only 2 to 3
months. Second, TCF repair using various techniques has been
successful with similar complication rates regardless of dura-
tion of TCF.1,8,9,11,14 The difference seen in our surgical times
can be explained by the increased complexity of TCF closure
and is not likely related to the duration of fistula. Therefore,
it is unlikely that the TCF fistula duration affected our com-
parison between TCF closure and excision. The disparity in TCF
duration in the excision and closure cohorts also brings to light
the possibility that some TCFs in the excision group may have
spontaneously closed if surgical repair was delayed until 6 or
8 months. Unfortunately, there are insufficient data to pre-
dict how many fistulas present at 3 months will be present at
6, 9, and 12 months. If such data existed, the usefulness of
closing TCFs earlier vs later would be another variable worth
investigating.
Measuring the length of stay can assess health care use for
procedures.18 The length of stay in the closure group was sta-
tistically longer than that in the excision group by almost 4-fold.
This difference exists because the excision group was rou-
tinely discharged home the day of surgery, whereas the clo-
sure group was observed overnight. This practice is novel and

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 Two Techniques of Tracheocutaneous Fistula Closure Original Investigation Research

has not been previously described to our knowledge. The ra-
tionale for same-day surgery for TCF excision is based on an-
ecdotal experience that the procedure carries a minimal risk
of serious complication.
One difference in health care use between the 2 groups was
the use of ICU observation. Another difference was the lon-
ger procedure duration in the closure group compared with the
excision group.
Differences in health care use can be summarized using
the estimated costs (Table 3). When closure and excision
group patients were admitted to a routine hospital floor, the
cost difference between them was approximately $500
because of variation in operating room times. However, in a
comparison between TCF excision plus same-day discharge
and TCF closure plus admission to a routine hospital floor or
PICU, the cost considerably increases by 2.6-fold and 4.3-
fold, respectively.
Comparing the length of stay and cost estimates with treat-
ment outcomes allows the health care efficiency of a particu-
lar therapy to be estimated.19 Assuming that our outcomes are
similar between study groups, TCF excision may be a more ef-
ficient treatment option than closure for TCF (because of de-
creased length of stay and cost), particularly if the patient is
sent home from same-day surgery. The caveat remains that
postoperative practices will vary throughout the country, de-
creasing the possible difference in efficiency observed in this
study. If the outcomes were dissimilar (because of increased
severity of complications in TCF closure), the difference in ef-
ficiency would be greater than that observed, offering more
support for TCF excision alone.
At our institution, we have routinely managed patients
undergoing TCF closure in the PICU to allow expeditious rec-
ognition and management of the possible severe complica-
tions. Based on the relative infrequency of severe complica-
tions (<10%),13 floor observation may be reasonable for most if
not all patients, particularly if patients with severe complica-
tions can be safely and effectively triaged and transferred to
the PICU when necessary. Realizing the capabilities of various
hospital units is vital to determining the ideal location for
postoperative observation. Ultimately, safety of the patient is
of utmost importance, but in this era of increased concern for
health care use, it is important to realize that our everyday
management decisions have significant downstream health
care costs.
Sampling bias is a limitation to this study because the iden-
tification of patients was done retrospectively using various
diagnostic and procedural codes. Another limitation is that ret-
rospective data collection inherently has an information bias.
As such, recorded data are possibly inaccurate, or details are
missing. The sample size may have limited our ability to sta-
tistically interpret some of our outcomes, specifically closure
success rates and complication rates. Using our rates of suc-
cess and complications as pilot data, a future prospective study
would require a sample size of 141 patients (0.8 power with con-
tinuity correction [Statpages.org]) in each group to show
significant differences in both variables. Further comparison
between the study groups was limited by a lack of quality-of-
life assessment before and after the surgical repair. The eco-
nomic data are another limitation in that the exact cost of each
procedure was unavailable; therefore, cost means in each study
group were unable to be calculated.
A complete understanding of which procedure is more ef-
ficient remains an unrealized ideal at this point because the
natural history of TCF, influence on quality of life, cost of per-
sistent TCF, cost of TCF closure complications, and fre-
quency and cost of scar revision after healing by secondary in-
tent are not accurately known. As such, the treatment choice
requires individual analysis of the risks and benefits as cur-
rently appreciated.
Conclusions
Tracheocutaneous repair can be successfully achieved via fis-
tula excision with or without closure. Further assessment of
the natural history of TCFs and quality of life of patients with
TCF will help to determine appropriate timing of repair. Tra-
cheocutaneous fistula excision alone may be associated with
more efficient health care use than TCF with closure. A true
understanding of the efficiency will require more complete
comparison of the functional and cosmetic outcomes and com-
plication rates of these 2 surgical techniques.

ARTICLE INFORMATION Administrative, technical, or material support: 3. Al-Samri M, Mitchell I, Drummond DS, Bjornson
Submitted for Publication: September 3, 2013; Simons, Mehta. C. Tracheostomy in children: a population-based
final revision received November 12, 2013; Study supervision: Simons, Mehta. experience over 17 years. Pediatr Pulmonol.
accepted December 4, 2013. Conflict of Interest Disclosures: None reported. 2010;45(5):487-493.

Published Online: January 30, 2014.
doi:10.1001/jamaoto.2013.6521.
Author Contributions: Dr Wine had full access to
all the data in the study and takes responsibility for
the integrity of the data and the accuracy of the
data analysis.
Study concept and design: All authors.
Acquisition of data: Wine.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: Wine.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Wine.
Previous Presentation: This research was
presented at the 28th Annual Meeting of the
American Society of Pediatric Otolaryngology; April
26, 2013; Arlington, Virginia.
REFERENCES
1. Tasca RA, Clarke RW. Tracheocutaneous fistula
following paediatric tracheostomy: a 14-year
experience at Alder Hey Children’s Hospital. Int J
Pediatr Otorhinolaryngol. 2010;74(6):711-712.
2. Colman KL, Mandell DL, Simons JP. Impact of
stoma maturation on pediatric tracheostomy-
related complications. Arch Otolaryngol Head Neck
Surg. 2010;136(5):471-474.
4. Carron JD, Derkay CS, Strope GL, Nosonchuk JE,
Darrow DH. Pediatric tracheotomies: changing
indications and outcomes. Laryngoscope.
2000;110(7):1099-1104.
5. Oliver P, Richardson JR, Clubb RW, Flake CG.
Tracheotomy in children. N Engl J Med.
1962;267:631-637.
6. Tucker JA, Silberman HD. Tracheotomy in
pediatrics. Ann Otol Rhinol Laryngol.
1972;81(6):818-824.
7. Arcand P, Granger J. Pediatric tracheostomies:
changing trends. J Otolaryngol. 1988;17(2):121-124.

jamaotolaryngology.com JAMA Otolaryngology–Head & Neck Surgery March 2014 Volume 140, Number 3 241

Copyright 2014 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ on 06/07/2023

 Research Original Investigation
8. White AK, Smitheringale AJ. Treatment of
tracheocutaneous fistulae in children.
J Otolaryngol. 1989;18(1):49-52.
9. Schroeder JW Jr, Greene RM, Holinger LD.
Primary closure of persistent tracheocutaneous
fistula in pediatric patients. J Pediatr Surg.
2008;43(10):1786-1790.
10. Geyer M, Kubba H, Hartley B. Experiences of
tracheocutaneous fistula closure in children: how
we do it. Clin Otolaryngol. 2008;33(4):367-369.
11. Stern Y, Cosenza M, Walner DL, Cotton RT.
Management of persistent tracheocutaneous fistula
in the pediatric age group. Ann Otol Rhinol Laryngol.
1999;108(9):880-883.
12. Licameli GR, Marsh BR, Tunkel DE. A simple
method for closure of tracheocutaneous fistula in
242 JAMA Otolaryngology–Head & Neck Surgery March 2014 Volume 140, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ on 06/07/2023
children. Arch Otolaryngol Head Neck Surg.
1997;123(10):1066-1068.
13. Drezner DA, Cantrell H. Surgical management of
tracheocutaneous fistula. Ear Nose Throat J.
1998;77(7):534-537.
14. Osborn AJ, de Alarcón A, Hart CK, Cotton RT,
Rutter MJ. Tracheocutaneous fistula closure in the
pediatric population: should secondary closure be
the standard of care? Otolaryngol Head Neck Surg.
2013;149(5):766-771.
15. Wiel E, Fayoux P, Vilette B. Complications of
surgical closure of tracheo-cutaneous fistula in
pediatric patients: two case reports. Int J Pediatr
Otorhinolaryngol. 2000;52(1):97-99.
16. Mohan VK, Kashyap L, Verma S. Life
threatening subcutaneous emphysema following
Two Techniques of Tracheocutaneous Fistula Closure
surgical repair of tracheocutaneous fistula. Paediatr
Anaesth. 2003;13(4):339-341.
17. Priestley JD, Berkowitz RG. Closure of
tracheocutaneous fistula in children. Int J Pediatr
Otorhinolaryngol. 2006;70(8):1357-1359.
18. Leap Frog Group. Fact sheet: efficiency
measures (resource utilization). http://www
.leapfroggroup.org/media/file/FactSheet
_ResourceUtilization.pdf. Accessed December 13,
2013.
19. McGlynn EA. Identifying, Categorizing, and
Evaluating Health Care Efficiency Measures:
Executive Summary. Rockville, MD: Agency for
Healthcare Research and Quality; April 2008.
AHRQ publication 08-0030.
jamaotolaryngology.com