Case report: acute management of external laryngeal trauma

External laryngeal trauma is rare, accounting for less than 1% of all trauma cases seen at major centers. We report the case of a man who experienced multiple injuries, including an external laryngeal trauma. The primary signs and symptoms of his laryngeal trauma were hoarseness, hemoptysis, the loss of his laryngeal prominence (Adam's apple), neck tenderness, traumatic emphysema in the neck, and a small penetrating wound to the right of the laryngeal prominence. The patient underwent immediate tracheostomy and surgical exploration. On long-term followup, his voice quality and airway patency improved. This case illustrates the importance of rapid identification and early management of laryngotracheal trauma in a patient with multiple injuries.     

Tracheo-innominate artery fistula with severe motor and intellectual disability: Incidence and therapeutic management

Objective

Tracheo-innominate artery fistula (TIF) is a rare but life-threatening complication following tracheostomy or tracheoesophageal diversion (TED). Although successful surgical intervention for TIF has been reported, few studies have been performed in patients with severe motor and intellectual disability (SMID). Therefore, we aimed to analyze TIF in patients with SMID to clarify the clinical variables predicting the occurrence and adequate management for lifesaving of TIF.

Methods

We retrospectively reviewed the records of patients with SMID undergoing surgical tracheostomy and TED between 2006 and 2012 and identified those with TIF. When TIF occurred, we obtained the clinical status and emergency management.

Results

Of 70 patients who underwent tracheostomy or TED during the study period, three patients had TIFs; in one case, TIF was avoided by ligation of the innominate artery before TED. The incidence of TIF in those undergoing tracheostomy and TED was 2.3% and 7.4%, respectively. The interval between tracheostomy and TIF was 14–50 months.

Conclusions

Patients with SMID may have an increased risk of TIF. Prompt diagnosis and surgical intervention to control the bleeding is the only effective management at present.     

Endoscopic management of blunt pediatric laryngeal trauma

OBJECTIVES: Blunt laryngeal trauma in the pediatric population is an uncommon but unique entity that can be potentially life-threatening. Given the infrequency of these events, its management can pose a clinical dilemma. The authors review the evaluation and treatment of blunt pediatric laryngeal trauma. METHODS: We present a case report and a review of the literature. RESULTS: We describe the case of a 3-year-old boy who presented with laryngeal injury following blunt trauma. The patient sustained endolaryngeal hematomas and mucosal lacerations with exposed cartilage. After mucosal approximation, the patient was successfully managed in a critical care setting without a tracheostomy. CONCLUSIONS: With an appropriate and thorough evaluation of the pediatric patient, endoscopic management without a surgical airway may be considered as a viable alternative for blunt laryngeal trauma.     

Anesthetic and surgical management of tracheostomy in a patient with COVID-19

ObjectiveThe ongoing pandemic coronavirus disease-2019 (COVID-19) infection causes severe respiratory dysfunction and has become an emergent issue for worldwide healthcare. Since COVID-19 spreads through contact and droplet infection routes, careful attention to infection control and surgical management is important to prevent cross-contamination of patients and medical staff. Tracheostomy is an effective method to treat severe respiratory dysfunction with prolonged respiratory management and should be performed as a high-risk procedureMethodThe anesthetic and surgical considerations in this case involved difficult goals of the patient safety and the management of infection among health care workers. Our surgical procedure was developed based on the previous experiences of severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV).ResultsWe described the management procedures for tracheostomy in a patient with COVID-19, including the anesthesia preparation, surgical procedures, required medical supplies (a N95 mask or powered air purifying respirator, goggles, face shield, cap, double gloves, and a water-resistant disposable gown), and appropriate consultation with an infection prevention team.ConclusionAppropriate contact, airborne precautions, and sufficient use of muscle relaxants are essential for performing tracheostomy in a patient with COVID-19.     

Diaphragmatic rupture due to violent cough during tracheostomy

We present herein a rare case of diaphragmatic rupture due to violent coughing during tracheostomy. A 73-year-old man was admitted with cough, hoarseness and dysphagia caused by a huge laryngeal cancer obstructing the airways. Immediate emergency tracheostomy was performed, during which he experienced violent paroxysmal coughing, and he began to complain of right upper abdominal discomfort after tracheostomy. Chest radiography and computed tomography 4 days later showed right diaphragmatic rupture, through which small bowel loops had herniated into the right hemithorax. Diaphragmatic rupture with a 20-cm long fresh oblique tear was repaired through subsequent surgical treatment. Violent paroxysmal coughing during tracheostomy was considered likely to have caused this rare complication.     

Neonatal tracheal rupture complicating endotracheal intubation: a case report and indications for conservative management

Neonatal tracheal injury represents a rare complication of endotracheal intubation. Previous case reports have demonstrated high morbidity and mortality (75%) associated with the rapid occurrence of subcutaneous emphysema, respiratory failure and death in this patient population. This mandates the prompt recognition, evaluation and management of this injury in the neonate. Although there is no clear consensus, previous authors have described both surgical therapy and expectant management. We report a case of a newborn who sustained tracheal rupture following traumatic intubation who survived with expectant management. The pathophysiology, management and indications for conservative management of neonatal tracheal rupture are reviewed.     

Tracheo-innominate artery fistula: a rare complication in a laryngectomized patient

A tracheo-innominate artery fistula is an uncommon but frequently fatal complication of tracheostomy. Rarely, it can also occur in laryngectomized patients. We report a post-laryngectomy, post-radiotherapy patient using a metal tracheostomy tube, who developed a tracheo-innominate artery fistula about two months after radiotherapy. To our knowledge this is only the second reported case in a laryngectomized patient. The computed tomography (CT) angiography findings helped confirm the diagnosis and the patient was successfully managed by surgical exploration and ligation of the innominate artery. Coagulase negative Staphylococcus aureus was cultured from a tracheal swab. The clinical features, CT angiography findings, management protocols and possible aetiological factors are discussed.     

The management of carotid artery rupture

Carotid artery rupture is fortunately an uncommon complication of head and neck cancer treatment. Eleven episodes of carotid artery rupture following irradiation and major head and neck resection were identified over a 6-year period. We review our experience and discuss the predisposing factors that can cause this complication, important aspects of management and outcome. During this 6-year period, 11 episodes of carotid artery rupture were treated in our unit. All patients had received prior irradiation (more than 60 Gy) and undergone a major surgical resection or resections. The average age was 59 years; all patients had a salivary fistula, local infection and a manifest herald bleed just before their major carotid artery rupture. These patients were resuscitated, taken to theatre and the neck explored, with control of the vessel and debridement of necrotic tissue. Soft tissue coverage was in the form of a flap. Many of the factors predisposing to carotid artery rupture can be ameliorated or treated early in order to avoid this complication. Early and aggressive nutritional support together with correction of haematological abnormalities promote wound healing and prevent tissue breakdown. The detection and treatment of infection also reduces fistula formation and wound compromise. We present our protocol for the early, aggressive management of these patients with carotid artery rupture.     

Tracheoesophageal fistula: New option in management

Tracheoesophageal fistula is a life threatening condition. Patients not managed surgically ultimately die of their disease. Surgical management is the treatment of choice. We present a case of a patient that developed a tracheoesophageal fistula after tracheostomy. Surgical repair was done which failed due to infection. The patient was managed with the help of an esophageal stent and Trichloroacetic Acid cautery. This approach can be used in selected patients, depending upon the size and site of TEE Larger fistulae and those situated lower down e.g. supra carinal cannot be managed by this technique.     

A case with tracheo-innominate artery fistula. Successful management of endovascular embolization of innominate artery

Tracheo-innominate artery fistula (TIF) is known as a fatal complication after tracheostomy. We report a 9-year-old girl with early hypoxic encephalopathy who had a tracheo-innominate artery fistula with exsanguinating hemorrhage from her tracheostoma 10 months after tracheostomy. After temporary control of bleeding, embolization of the innominate artery was performed. The patient has remained well 1 year after the procedure. We reviewed the aetiology, diagnosis and management of the tracheo-innominate fistula, and findings suggest that endovascular embolization of the innominate artery may be an appropriate treatment for patients with tracheo-innominate artery fistula.     

A review of the current management of infantile subglottic haemangioma,including a comparison of CO(2) laser therapy versus tracheostomy

OBJECTIVES: We reassessed the current practice and treatment options used in the management of subglottic haemangiomas (SGHs), including the place for open submucosal surgical excision, and have compared the results of different therapeutic modalities used for SGHs. METHODS: The two studies were conducted as separate exercises; (1) a retrospective review of 36 patients collected over a recent 8-year period to assess the current practice and treatment options in use; (2) a retrospective comparative study of a previous cohort of 51 patients with SGHs treated in one of four groups: (a) tracheostomy alone, (b) tracheostomy and CO(2) laser, (c) systemic steroids and CO(2) laser (no tracheostomy) and (d) intralesional steroid injection, CO(2) laser therapy, or both, followed by intubation. RESULTS: Systemic steroids were the most commonly used modality of treatment. Resolution of the SGH was achieved in 89% of cases at a mean follow up duration of 34 months. However, tracheostomy was required in 58% of cases, with a mean time from diagnosis to decannulation of 30 months. The time to resolution of SGHs does not appear to be reduced by laser therapy compared with treatment by tracheostomy alone. Intralesional steroid injection or laser therapy together with intubation was associated with avoidance of a tracheostomy in 66% of cases. Single-stage open surgical excision in two cases resulted in successful resolution of the SGH and discharge after a mean follow up period of 3 months. CONCLUSIONS: Despite the more widespread use of steroids and other treatment modalities, the requirement for tracheostomy has remained unchanged over the last 20 years. The use of laser therapy does not appear to confer any additional therapeutic benefit over and above tracheostomy alone in bringing about resolution of SGHs. Systemic steroids may reduce the size of the haemangioma but are associated with multiple adverse effects. The decision to use the above techniques must, therefore, be made in the light of these observations. Our early experience of single-stage excision suggests that this technique represents an exciting and promising surgical alternative, and its more widespread adoption may be the only way of further improving the outcome of patients with SGHs.     

Congenital cervical teratomas: diagnostic, management and postoperative variability

OBJECTIVE: To review the diagnosis, management and outcomes of congenital cervical teratomas presenting to a tertiary referral centre. METHODS: Retrospective chart review of three cases presenting within an 18-month period. RESULTS: Of the three patients in this series, one was diagnosed antenatally. The remaining cases were diagnosed at birth. The antenatally diagnosed patient underwent an EXIT procedure whereby the airway was secured by tracheostomy. This patient subsequently died 30 min after separation from the materno-foetal circulation. Neither of the other two cases had any neonatal respiratory distress, despite having large tumours. Both patients had neonatal surgical excision of the teratomas performed. Both patients had postoperative respiratory distress, requiring intervention. Both patients made a full recovery. No recurrence has been reported. CONCLUSION: The antenatal diagnosis of large congenital cervical teratomas allows for planned intervention by experienced personnel. A successful outcome may not be obtained. All patients that undergo surgical excision of these tumours must be closely observed for post-operative respiratory distress, even in the absence of pre-operative symptoms.     

Traumatic retropharyngeal hematoma: case report

Traumatic retropharyngeal hematoma is a rare but potentially life-threatening condition that requires an early diagnosis. Isolated retropharyngeal hematoma without an associated cervical fracture is a relatively rare condition. The treatment of retropharyngeal hematoma is conservative in most cases, with close observation. The indications for surgical evacuation of hematomas are large size, difficult with mechanical ventilation and failure to improve with medical therapy. We present the case of a 50-year-old man with retropharyngeal hematoma with a compromised airway due to minor contusion of the neck, which required surgical intervention. The patient underwent emergent surgical debridement and tracheostomy. Postoperative course was uneventful. The patient was discharged 9 days later. Early surgical intervention can reduce the hospital stay, resulting in a rapid convalescence.     

External laryngotracheal trauma in children.

External laryngotracheal trauma in the paediatric population, although rare, presents a diagnostic and therapeutic dilemma for the attending surgeon. The purpose of this study was to evaluate the clinical profile, treatment and outcome and to establish a simple, effective management protocol in this emergency. A retrospective case series was studied. There were 12 patients aged 2-14 years in this series, eight of them (67%) having closed injuries. Their clinical presentation was correlated to conservative management, tracheostomy and surgical intervention. In the open injury group all the patients (100%) underwent tracheostomy, upper endoscopy and neck exploration. One patient (25%) in this group developed subglottic stenosis. In the closed injury group, seven patients (88%) had tracheostomy with upper endoscopy, and two of them (25%) had neck exploration in addition. One patient (13%), however, developed glottic stenosis. The patients with stenosis underwent multiple surgical interventions prior to final decannulation. There was no mortality. Breathing difficulty/stridor were the commonest clinical presentations in children with acute external laryngotracheal trauma. Tracheostomy and early surgical intervention appeared to be the treatment of choice. A protocol with major and minor criteria of clinical presentation is suggested for effective management.     

Endoscopic airway management of acute upper airway obstruction

The conventional treatment for patients with acute upper airway obstruction is tracheostomy, which is a safe, definitive procedure in most hands. Alternatively, a debulking procedure can be considered but this requires both surgical and anaesthetic skill and expertise. However, where possible, it provides a good alternative with the advantages of removing the cause of obstruction and yielding tissue for histopathological analysis, and avoiding the need for a tracheostomy, with its associated morbidity. We evaluated all patients who presented with acute upper airway obstruction and underwent endoscopic laser debulking surgery performed by the senior author, over a three and a half year period. We recorded patient demographic data, their underlying pathologies, complication rates associated with laser debulking surgery and the conversion to tracheostomy. Thirty patients were identified, including 19 males and 11 females, with a mean age of 57.10 ± 17.20 years (19–93 years). All patients underwent debulking procedures with carbon dioxide laser under general anaesthetic. All patients had their underlying diagnosis confirmed from their debulking surgery. Twelve patients were found to have benign pathology and 18 had malignant airway obstruction. There were no laser-associated complications. One patient required conversion to emergency tracheostomy, during their debulking surgery. Endoscopic laser assisted debulking surgery has successfully been used to establish a safe airway. It allows obtaining tissue specimens, to confirm the underlying diagnosis, thus avoiding the need for further biopsies under anaesthetic. For all malignant cases, patients were subsequently able to proceed to definitive treatment. It has obviated the need for emergency tracheostomy in almost all of the cases in our patient cohort.     

Anesthetic and operative management of potential upper airway obstruction.

Potential or actual supraglottic airway obstruction becomes critical when general anesthesia is begun. Four cases illustrated such obstruction, and the anesthetic and surgical management of each condition was critical. In carcinoma of the supraglottic larynx and in pharyngeal abscess, the unobstructed airway in the conscious patient became impossible to secure once general anesthesia was begun. Unappreciated pathological deformity prohibited endotracheal intubation, and anesthesia precipitated obstruction. In epiglottitis and peritonsillar abscess, the nature of the impending airway obstruction was appreciated, and the selection of a safe technique to secure the airway was made. Anesthetic and surgical management of potential supraglottic obstruction includes five options: (1) oral tracheal intubation by laryngoscopy while the patient is awake; (2) awake nasotracheal intubation; (3) inhalation induction by general anesthesia with intubation; (4) rapid induction with barbiturates and muscle relaxants with intubation; and (5) tracheostomy with local anesthesia.     

Ectopic thymic tissue in subglottis of children: evaluation and management

ObjectivesEctopic thymic tissue in the subglottis is an extremely rare disease that causes airway obstruction. Few cases reported were accurately diagnosed before surgery.MethodsA case of a 2-year-old boy with airway obstruction caused by a left subglottic mass was reported. The presentation of radiological imaging, direct laryngoscopy and bronchoscopy, pathology, and surgical management were reviewed. An extensive search in PubMed, EMBASE, Web of Science, Google Scholar, and EBSCO of English literature was performed without a limit of time.ResultsBesides our case, only six cases were reported since 1987. The definitive diagnosis on these patients were made with the findings of pathology, of which, five were ectopic thymus and two were ectopic thymic cysts. Our case was the only one with a correct suspicion preoperatively. Four cases underwent open surgical resection, and two cases underwent microlaryngeal surgery, while one deceased after emergency tracheostomy. No recurrences were found by six patients during the follow-up after successful treatments.ConclusionEctopic thymus is a rare condition, infrequently considered in the differential diagnosis of subglottic masses. Modified laryngofissure may be an effective approach to removing the subglottic ectopic thymus and reconstructing the intact subglottic mucosa.     

Airway management after maxillectomy: routine tracheostomy is unnecessary

OBJECTIVES/HYPOTHESIS: There is a paucity of data to guide the optimal management of the airway in patients after maxillectomy. The decision on whether a concomitant tracheostomy is needed is often dictated by the surgeon's training and experience. We reviewed our experience with maxillectomy to assess the need for tracheostomy in postoperative airway management. STUDY DESIGN: Retrospective analysis at a university hospital. METHODS: We identified 121 patients who underwent 130 maxillectomies between October 1990 and September 2001. Twenty-four of these were total (all six walls removed), 45 were subtotal (two or more walls removed), and 61 were limited (only one wall removed). Reconstruction ranged from none to microvascular free flap, with split-thickness skin graft being the most common reconstructive option. RESULTS: Only 10 tracheostomies (7.7%) were performed at the time of maxillectomy. These included four tracheostomies in patients who underwent bulky flap reconstruction, two tracheostomies in patients who underwent both flap reconstruction and mandibulectomy, one tracheostomy in a patient who underwent mandibulectomy, one tracheostomy in a patient with mucormycosis in anticipation of prolonged ventilatory support postoperatively, and two tracheostomies at the surgeons' discretion because of concern for upper airway edema. Among the 111 patients who underwent 120 maxillectomies without concomitant tracheostomy, 1 patient (0.9%), a 74 year-old man with oxygen-dependent chronic obstructive pulmonary disease, required repeat intubation on day 3 and again on day 10 after the surgery, because of respiratory failure; fiberoptic examination confirmed the absence of upper airway compromise. CONCLUSIONS: The routine performance of tracheostomy in patients undergoing maxillectomy is unnecessary. Selective use of tracheostomy may be indicated in situations in which mandibulectomy or bulky flap reconstruction is performed or a concern for postoperative oropharyngeal airway obstruction because of edema or packing exists.     

Emergency tracheal catheterization for jet ventilation: a role for the ENT surgeon?

Stridor causing respiratory failure is an ENT and anaesthetic emergency requiring prompt management to secure a clear airway. We describe a case of subacute partial upper airway obstruction due to a large laryngeal carcinoma in an 81-year-old male resulting in respiratory failure. The patient became apnoeic after gaseous induction of general anaesthesia, and after two failed intubation attempts an emergency transtracheal airway catheter was placed by the surgeon under direct vision below the cricothyroid membrane, as this had tumour involvement. The patient was subsequently manually jet-ventilated with ease until a formal tracheostomy was made. Where difficulties with tracheal anatomy are encountered due to the presence of pathology, the insertion of a temporary airway catheter for jet ventilation by the surgeon can buy valuable time and be life-saving.     

Warfarin-induced sublingual hematoma mimicking Ludwig angina: Conservative management of a potentially life-threatening condition

Sublingual hematoma secondary to excessive anticoagulation is a rare, life-threatening condition. Reports in the literature have emphasized the importance of a prompt reversal of the causative coagulopathy by intravenous administration of vitamin K and fresh frozen plasma. In the event of an unstable airway, surgical intervention via tracheostomy or cricothyroidectomy is advocated. We report a case of sublingual hematoma that was treated conservatively, and we discuss the presentation and management of this entity.