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Table of Contents
CASE REPORTS
Year : 2021  |  Volume : 5  |  Issue : 4  |  Page : 263-266

Airway obstruction by subcutaneous tissues growing into tracheal lumen below tracheostomy stoma: A case report


Divisional Railway Hospital, Southern Railway, Madurai, Tamil Nadu, India

Date of Submission16-Apr-2021
Date of Decision16-Apr-2021
Date of Acceptance30-May-2021
Date of Web Publication24-Nov-2021

Correspondence Address:
Dr. Indrajith Renjith
Divisional Railway Hospital, Near SBI ATM, Southern Railway Colony, Madurai, Tamil Nadu 625016.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjoa.BJOA_45_21

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  Abstract 

Tube obstruction is one of the common complications of tracheostomy. The most frequent cause of tube obstruction is the plugging of tracheostomy tube with mucous plug, clots, or crust. We report a case of low tracheostomy obstructed by a mass of subcutaneous tissue proliferating into the tracheal lumen. When the patient was posted for radical surgery, trachea was cannulated using a regular endotracheal tube (ETT) inserted into the stoma under fiber optic bronchoscope guidance, and general anesthesia was administered. Anatomically distorted tracheostomy tracts may be maintained with customized tracheostomy tubes if available to prevent complications. Any difficulty in inserting tracheostomy tube can be temporarily managed with the ETT inserted into the stoma.

Keywords: Airway obstruction, secondary care hospital, tracheostomy


How to cite this article:
Renjith I, Revathi R. Airway obstruction by subcutaneous tissues growing into tracheal lumen below tracheostomy stoma: A case report. Bali J Anaesthesiol 2021;5:263-6

How to cite this URL:
Renjith I, Revathi R. Airway obstruction by subcutaneous tissues growing into tracheal lumen below tracheostomy stoma: A case report. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Nov 28];5:263-6. Available from: https://www.bjoaonline.com/text.asp?2021/5/4/263/330949




  Introduction Top


Laryngeal and thyroid malignancies with tracheal invasion often result in airway obstruction or tracheal stenosis. Airway management for surgery can be challenging in such patients and often needs individualized management plan. Several case reports have been published so far, which discuss different strategies of airway management in such entities.[1],[2],[3],[4],[5] Awake tracheotomy can be a strategy usually performed in patients with stenotic tumors in larynx and hypopharynx.[6]

Tracheostomy is associated with numerous complications. Tube obstruction is one of the common complications of tracheostomy. The most frequent cause of tube obstruction is the plugging of tracheostomy tube with mucous plug, clots, or crust. Here we report a rare case of low tracheostomy obstructed by a mass of subcutaneous tissue proliferating into the tracheal lumen. When the patient was posted for radical surgery, trachea was cannulated using a regular endotracheal tube (ETT) inserted into the stoma under fiber optic bronchoscope guidance, and general anesthesia was administered.


  Case Report Top


A 65-year-old-male, chronic smoker, and a known case of chronic obstructive pulmonary disease (COPD) admitted with acute exacerbation of COPD and was initially managed with antibiotics, bronchodialators, and supportive measures. On examination, there was thyroid enlargement and features of airway obstruction are hoarseness of voice and early stridor. CT neck was suggestive of thyroid mass with tracheal invasion and intraluminal extension occluding 75% lumen. FNAC was suggestive of medullary neoplasm. Elective tracheostomy was done under local anesthesia. Since thyroid mass was extending down the stoma, it was created at the level of 5th tracheal ring. A cuffed portex tracheostomy tube of size 8.5 mm was inserted with little difficulty. The patient was comfortable after the procedure. Radical surgery was not done immediately because of unoptimized pulmonary status.

After 3 days, the patient became breathless and attempts of tracheal suctioning and repositioning of the tube failed. With a suspicion of tube occlusion, tracheostomy tube was changed over an airway exchange catheter with little difficulty through the same tract and the patient was comfortable. Next day again the patient became distressed with features of tube obstruction and surgical emphysema over the face and neck. On tracheostomy tube removal, the patient became clinically better. But further attempts to insert smaller sized tubes (7.5 and 7.0 mm) resulted in airway obstruction. Since the patient was comfortable without tracheostomy tube, it was decided to leave the stoma intact with close monitoring. Fiber optic bronchoscopy (FOB) was not done in this sitting due to non-availability of the equipment.

After 4 days, the patient was posted for radical surgery. In view of failed insertion of the tracheostomy tube, equipment for FOB was outsourced and FOB was done through the stoma. There was a smooth tissue bulge 2 cm below the stoma occluding the tracheal lumen [Figure 1]. On careful tracing, it was surprising to find that the bulge was actually a chunk of subcutaneous tissue proliferating down the tracheal lumen. Also the distance from the skin to tracheal stoma has increased drastically due to edema and surgical emphysema.
Figure 1: FOB image showing tissue bulge below the stoma occluding the tracheal lumen

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Two attempts to insert tracheostomy tube (7 and 7.5 mm portex cuffed) under FOB guidance failed as the tube tip was getting occluded. Hence, it was decided to put the cuffed ETT. ETT of size 7.0 mm was softened by immersing in warm water and successfully railroaded into the trachea under FOB guidance. Proximal part of ETT was cut to appropriate length and secured with stay sutures [Figure 2]. The patient was comfortable after the procedure and then taken for radical surgery under GA. Total thyroidectomy, total laryngectomy, and neck dissection were done [Figure 3]. During dissection around the stoma, the proliferated subcutaneous tissue which was seen as a bulge in FOB disappeared. The tracheostomy was revised and the tracheal stoma was pulled up and secured to skin using stay sutures. After surgery, ETT was removed and new tracheostomy tube size 8.0 was easily inserted. Post-operative period was uneventful and the patient is tolerating tracheostomy tube well.
Figure 2: Portex ETT inserted through the stoma under FOB guidance and cut to adequate length

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Figure 3: Intraoperative specimen showing larynx with upper tracheal rings and thyroid being removed en bloc

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  Discussion Top


There are numerous indications for tracheostomy and are associated with many complications.[7],[8] Tube obstruction is a common cause of respiratory compromise, which can lead to a life-threatening emergency if it is not properly managed.[9] The frequent cause of tracheostomy tube obstruction is the plugging of tube with mucus plug, clot, or secretions. But in this case tracheostomy tube was seen obstructed by a chunk of subcutaneous tissue proliferating into the trachea.

Anatomical challenges can make placement of a tracheostomy problematic.[10] Commercially available tracheostomy tubes come in preformed shapes that suit to the tract. But in this case stoma was very low and so the conventional tube was probably not matching with the anatomy of the tract. Certain manufacturers now offer customized tracheostomy tubes, but that is out of scope in limited resource setups.[10]

In this case, episodes of tube obstruction have caused surgical emphysema and tissue edema. This has increased the depth of tracheal stoma from the skin surface which might have worsened the anatomy of the tract and posed difficulty in inserting newer tracheostomy tubes. Early removal and placement of new tracheostomy tube through the abnormal tract probably would have dragged subcutaneous tissue inside the tracheal lumen, which later proliferated to form a tissue bulge occluding tracheal lumen.

In this case, FOB through the stoma helped to diagnose the cause of airway obstruction. There was a smooth tissue bulge seen proliferating inside the tracheal lumen. Attempts to rail road tracheostomy tube under FOB guidance failed because the tissue bulge was getting dragged along with the tube causing obstruction. Hence, regular ETT was softened by immersing in warm water for 5 min and easily negotiated beyond the tracheal obstruction under FOB guidance. The softened ETT could be easily molded to the shape of tracheostomy stoma. This technique of softening ETT by immersing in warm water for blind nasotracheal intubation has been reported in literature.[11] The modification of an ETT as a tracheostomy tube has been previously described.


  Conclusion Top


Anatomically distorted tracheostomy tracts may be maintained with customized tracheostomy tubes if available to prevent complications. Any case of tracheostomy with altered and difficult anatomy and having features of obstruction can be diagnosed and managed with FOB.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cho JW, Jeong MA, Choi JH, Cho JW, Lee HJ, Kim DW, et al. Anesthetic consideration for patients with severe tracheal obstruction caused by thyroid cancer—A report of 2 cases. Korean J Anesthesiol 2010;58:396-400.  Back to cited text no. 1
    
2.
Gilfillan N, Ball CM, Myles PS, Serpell J, Johnson WR, Paul E. A cohort and database study of airway management in patients undergoing thyroidectomy for retrosternal goitre. Anaesth Intensive Care 2014;42:700-8.  Back to cited text no. 2
    
3.
Piao M, Yuan Y, Wang Y, Feng C. Successful management of trachea stenosis with massive substernal goiter via tracheobronchial stent. J Cardiothorac Surg 2013;8:212.  Back to cited text no. 3
    
4.
Srivastava D, Dhiraaj S. Airway management of a difficult airway due to prolonged enlarged goiter using loco-sedative technique. Saudi J Anaesth 2013;7:86-9.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Piepho T, Cavus E, Noppens R, Byhahn C, Dörges V, Zwissler B, et al. S1 guidelines on airway management: Guideline of the German Society of Anesthesiology and Intensive Care Medicine. Anaesthesist 2015;64(Suppl. 1):27-40.  Back to cited text no. 5
    
6.
Adedeji T, Idowu J, Olaosun A, Tobih J. Indications and outcomes of tracheostomy: An experience in a resource-limited environment. J Health Res Rev 2014;1:40.  Back to cited text no. 6
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7.
Pawar P, Rajendra N, Jagan J, Sukumar S, Raju R. Tracheostomy creation leading to innominate artery pseudoaneurysm: A case report. Indian J Anaesth 2020;64:159-61.  Back to cited text no. 7
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8.
Cipriano A, Mao ML, Hon HH, Vazquez D, Stawicki SP, Sharpe RP, et al. An overview of complications associated with open and percutaneous tracheostomy procedures. Int J Crit Illn Inj Sci 2015;5:179-88.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Chiaravalli J, Lufesi N, Shawa E, Nkhoma V, Sigalet E, Dubrowski A. Management of an obstructed tracheostomy in a limited-resource setting. Cureus 2017;9:e1246.  Back to cited text no. 9
    
10.
Capuano U, Ferrara JJ. A modified endotracheal tube for tracheostomy. Crit Care Med 1986;14:521-2.  Back to cited text no. 10
    
11.
Hosseinzadeh H, Taheri Talesh K, Golzari SE, Gholizadeh H, Lotfi A, Hosseinzadeh P. Warming endotracheal tube in blind nasotracheal intubation throughout maxillofacial surgeries. J Cardiovasc Thorac Res 2013;5:147-51.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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