Anesthetic Management of Iatrogenic Tracheal Injury: A Case Report

Tracheal perforation following oesophagectomy is a very rare and occasionally life-threatening condition that requires a high degree of suspicion and early intervention for optimal patient outcomes. This article presents a case report of a 46-year-old male who presented with respiratory failure secondary to tracheal perforation at the level of carina following a two-stage oesophagectomy. He underwent a second emergency procedure; the airway was secured with a left-sided double-lumen tube, and tracheal perforation was successfully repaired. This case report will briefly cover the challenges and difficulties faced by anesthetists in the airway management, ventilation, and hemodynamic instability of such patients.

Delayed Tracheal Perforation After Partial Thyroidectomy: A Case Report and Review of the Literature

Tracheal perforation is an extremely rare and potentially dangerous complication of a partial thyroidectomy. The current case represents a unique presentation of delayed tracheal perforation following an uncomplicated thyroid isthmusectomy for tissue diagnosis of an aggressive appearing thyroid mass in the setting of high-dose steroid administration and recent intubation and self-extubation. While conservative management of tracheal perforation can sometimes be appropriate, our patient was successfully managed via primary closure and infrahyoid muscle transposition flap to cover a 5 mm right lateral tracheal wall defect. We recommend caution be exercised following thyroid surgery in the setting of intubation and high-dose steroids.

Necrotizing Tracheitis Complicated by Tracheal Wall Perforation

Necrotizing tracheitis is a rare condition, mainly seen in immunocompromised patients, that may lead to pseudomembrane formation, airway obstruction and in severe cases, tracheal perforation. We present a case of a 32-year-old male with poorly controlled diabetes who presented with productive cough, dysphagia, and respiratory distress. Bronchoscopy revealed extensive tracheal necrosis along a 4-5 cm segment of cartilaginous trachea and was complicated by tracheal perforation with false passage into the anterior mediastinum. Once the airway was re-established, a multidisciplinary team discussed options for definitive airway management, including tracheal reconstruction, pulmonary stent, or tracheostomy. Ultimately, a distal XLT tracheostomy was placed. Microbiology specimens of the tracheal tissue were positive for Actinomyces. The patient was started on long-term antibiotics and diabetes management. At three-month follow-up, the trachea was patent with near complete mucosalization of the previously necrotic segment. An area of proximal tracheal stenosis was successfully managed with a customized tracheal T-tube. In conclusion, this is a case of necrotizing tracheitis complicated by tracheal perforation. Successful treatment required a multidisciplinary team for airway management as well as medical treatment of immunocompromising risk factors and antimicrobial therapy. This enabled timely healing of the trachea and a durable airway.

Conservative Management of Large Tracheal Perforation due to Traumatic Intubation

Tracheal perforation is a rare complication of intubation and is associated with high mortality. Here we describe a case of large, full-thickness tracheal perforation from traumatic intubation after an elective procedure. The injury was managed with prolonged intubation that bypassed the site of injury, and the patient was successfully extubated after 11 days. Conservative management of tracheal perforation after traumatic intubation is an option in select patients that avoids need for surgery.

Delayed Tracheal Perforation Following Total Thyroidectomy

Delayed tracheal rupture following total thyroidectomy (TT) is rare and represents a potential airway emergency. A 34-year-old female with Felty Syndrome underwent TT for Hashimoto's thyroiditis. On post-operative day 10, she presented with subcutaneous emphysema and an anterolateral tracheal perforation on CT scan. Urgent operative exploration revealed transmural tracheal necrosis and a 5 mm perforation. This was oversewn with non-absorbable suture and a strap muscle flap rotated over the defect to promote healing. Repeat direct laryngoscopy at 72 hours revealed healing tissue. Tracheal necrosis and perforation following TT constitutes a potential airway emergency and should be promptly explored and repaired. Laryngoscope, 2021.

Postintubation Tracheal Perforation While on Long-Term Steroid Therapy: A Case Report

BACKGROUND

Endotracheal intubation is an essential basic skill for emergency physicians. The procedure can cause complications that should be recognized. Awareness and early identification of complications are needed to allow early intervention to optimize outcomes. The risk factors for tracheal perforation during intubation are typically related to the physician skill and experience and to the patient's comorbidities, including body habitus and chronic use of certain medications.

CASE REPORT

We report a case of a 45-year-old man with renal transplant on tacrolimus and prednisolone for 16 years. He presented with decreased level of consciousness due to an acute intracranial hemorrhage and was intubated for airway protection. Post intubation, a significant subcutaneous emphysema was noted on the patient's neck and chest, which was subsequently determined to be caused by a tracheal perforation. The management of tracheal injury depends on the size and location of the tear, as well as the patient's clinical status and comorbidities. In this case, the tracheal perforation was treated conservatively and was successful. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case has been reported to increase awareness about this rare and potentially life-threatening event. The prevention of this rare injury can be difficult but use of a slightly smaller endotracheal tube in a high-risk patient can be of benefit. In addition, early consideration of this complication when there is an acute change in physiologic status will allow for rapid facilitated management.

Endotracheal and tracheostomy tube-related complications: imaging with three-dimensional spiral computed tomography

AIM

To present our experience from the use of three-dimensional (3D) spiral computed tomography (CT) reconstructions for the detection of endotracheal and tracheostomy tube-related complications.

MATERIAL AND METHODS

The CT-scans of thirteen patients who were subjected to spiral computed tomography for the evaluation of possible tracheal complications due to the use of endotracheal or tracheostomy tubes were retrospectively studied. In each case, a spiral scan of the airways from the larynx to the main bronchi was performed. Axial images were reconstructed with the use of the following three-dimensional visualization methods: volume rendering (VR), tissue transition projection (TTP), shaded surface display (SSD) and virtual endoscopy (VE). Detected complications were subdivided into acute and late, according to the time of appearance (during presence of tracheal tube or after its removal, respectively).

RESULTS

Six patients showed acute complications (wrong placement of the tube with compression of tracheal wall in three cases, perforation of tracheal wall in two cases, tracheal stenosis in one case). Seven patients showed late complications (tracheal stenosis in all cases). Three-dimensional reformatted images contributed significantly to the detection of both acute complications (position of tube in relation to tracheal wall), and late complications (number, position, length and degree of stenoses), providing a non-invasive evaluation of the outer tracheal wall and tracheal lumen.

CONCLUSION

Three-dimensional spiral CT reconstructions are a valuable adjunct of transverse images for the evaluation of trachea in cases of suspected tracheal tube-related complications.

Lethal tracheal dissolution during treatment for thyroid lymphoma

Background - A case of primary thyroid T cell lymphoma leading to lethal tracheal perforation during chemotherapy is described.

Tracheal perforation and widespread subcutaneous emphysema in a horse

A twelve year old Quarterhorse mare exhibited subcutaneous emphysema of the head, neck, upper forelimbs and thorax, and walked with a stiff gait, characterized by decreased flexion of the forelimbs. Endoscopy of the trachea revealed a small tracheal wound ninety centimeters from the external nares. The location of the lesion corresponded with a seroma present at the base of the neck. The subcutaneous emphysema and the seroma resolved without specific therapy. Blunt trauma was suggested as the cause of the tracheal lesion and subsequent subcutaneous emphysema.