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It is difficult but challenging to care for the airways of patients who are severely handicapped both mentally and physically. Tracheostomy is usually selected when conservative procedures are no longer effective. However, tracheostomy itself can cause swallowing problems. The most reliable management procedure for aspiration is an operation through which the laryngeal function is sacrificed such as total laryngectomy or laryngotracheal separation. Aspiration can be well controlled with this technique. However, in some patients who undergo such procedures airway stenosis develops, which finally causes their death. Tracheal stenosis may devolop due to the following factors; 1) scar formation resulting from granulation tissues produced by the cuff or tip of nasotracheal tubes or tracheostomy tubes; 2) posterior compression by the thoracic vertebrae due to their abnormal arrangement, such as scoliosis and loss of physiological kyphosis, which is related to the poor posture caused by the primary disease; or 3) a fragile tracheal structure. Two cases, an 11-year-old girl with spastic cerebral palsy and a 4-year-old boy with arthrogryposis multiplex congenita, who developed permanent tracheostoma followed by tracheal stenosis were presented. The former died from massive intratracheal bleeding due to the rupture of the brachiocephalic artery, and the latter died from inflammatory airway obstruction. Tracheomalacia in the severely handicapped should be regarded as a prognostic factor against surgery to stop aspiration, and therefore it must be checked before surgery.

Tracheomalacia Influences Surgical Prognosis for Airway Obstruction or Aspiration in Severely Handicapped Patients.