Reprinted with permission of the author

When your laryngectomy was done, part of the reconstruction was to create your stoma.  This was done by suturing the cut end of your trachea to the skin of your lower neck.  Under ideal circumstances we want the stoma to be at least as big as the diameter of your trachea, but actually hope that it might be slightly bigger.  So why do they get smaller with time?  Several factors are at work.  Any time we create a surgical wound, and the stoma is certainly a surgical wound, the body responds by laying down scar tissue as a natural part of the healing process.  Scar tissue is very dense and tough, much more so than surrounding normal tissue.  Scar tissue has one tendency that will ultimately affect the final result and that is CONTRACTURE.  That's right, by their very nature, all scars get SMALLER.  Usually that's not a problem for linear scars on the skin but when the contracting scar involves a round opening, then the possibilities become quite obvious. The opening will get smaller.

There are several things that contribute to a small stoma.  These include not removing enough skin from the lower neck during the surgery, compromising the blood supply to the cut end of the trachea, putting in too many sutures, too much tension on the trachea-skin suture line, poor nutrition, prior irradiation to the neck, and infection.  Also, some folks just simply have a small trachea from the start so their stomas naturally will be smaller. 

So how do we (as surgeons) manage the stoma and try to reduce the risk of shrinkage or stenosis.  Well, the first thing we try to do is to avoid or correct those things that I mentioned above.  The second thing we try to do is control the scarring and shrinking process that we all know will occur as you heal.  This includes vigorous stomal hygiene to cut down on crust formation and infection.  Humidification is important as well.  We will also place a small soft stoma vent that can be worn after surgery which will hopefully cause the shrinking scar to mature in an open position.  This vent can be removed for cleaning and inspection of the stoma.

So what is the ideal size for a stoma?  The answer varies for each patient.  The opening should be large enough for adequate airflow so you don't experience any shortness of breath at rest or with exercise.  It should be large enough to allow you to remove crusts and secretions with
ease.  The kicker comes in with the insertion of a speech prosthesis. Since the prosthesis itself takes up some room it will reduce the cross-sectional area of the stoma.  Therefore, we generally like to see a stoma at least 1.5 to 2 cm in diameter before entertaining doing the TEP.

So what do we do for a small stoma?  There are several schools of thought here.  There are a number of surgical procedures, which have been developed for the correction of stomal stenosis.  The problem with more surgery is what?  That's right.  More contracting scar tissue! Therefore, I have started dilating or stretching small stomas with progressively larger stoma vents.  This takes longer to achieve your desired goal, but avoids the vicious cycle of surgery, scar, and more contracture.