Cervical rib is a congenital phenomenon that usually occurs in association with upper-limb neurovascular symptoms. The presence of a cervical rib displaces the great vessels that cross the thoracic outlet superiorly and proceed into the neck. We report an unusual case of iatrogenic hemorrhage during a tracheostomy in a patient whose right subclavian artery had been displaced by a cervical rib. Our aim is to alert surgeons to the hidden risks of this phenomenon.
A method of treating tracheostomal stenosis post-laryngectomy is described. The carbon dioxide (CO2) laser is used to fashion and ablate two triangular areas lateral to the stenosed stoma to provide an immediate enlarged stoma for comfortable breathing. This simple procedure is done under local anaesthesia, is almost bloodless, safe and takes just 10 minutes. Over the last five years eight patients underwent this procedure and seven had a satisfactory stoma without the need to use a tracheostomy tube.
A 6 years old girl accidentally aspirated a plastic whistle while playing. Computed Tomography of thorax showed foreign body at carina level. Rigid bronchoscope under general anesthesia was attempted but unable to extract the whistle through vocal cord. Tracheostomy was later performed and foreign body was removed.
A 19 year-old man was presented to us in a state of respiratory distress with history of alleged accidentally swallowed the live fish. Flexible nasopharyngolaryngoscope showed a big live fish impacted in the laryngopharynx. Attempts to remove the fish orally were futile as the fish was impacted. We resorted to tracheostomy under local anaesthesia, followed by direct laryngoscopy and removal of the fish under general anaesthesia. The literature review of such rare incidence and approach to such case are discussed.
Eighty-five children who presented with stridor were reviewed in order to determine the aetiology of stridor in these cases. Congenital causes accounted for 57.6% of cases. Laryngomalacia was the commonest congenital abnormality (77.5%). Other common causes of stridor were a foreign body in the airway (acquired) and laryngotracheobronchitis (33.3%) (infective). Tracheostomized children are a problem in developing countries, requiring prolonged hospitalization. We overcome this problem by teaching parents how to maintain the tracheostomy tube at home.
The upper airway is a crucial structure. It becomes a grave problem should it be narrowed. Several methods
of treatment were rendered for patients with laryngotracheal stenosis. We share our experience with the
combination total intravenous anaesthesia and apneic pause technique with or without steroid injection.
Four cases of laryngotracheal stenosis were observed in Hospital Ampang: two adult and two paediatric
cases. Age, gender, causative factor, stenosis segment length, grade or severity were observed before and
after dilatation, number of dilatation were observed and compared. The outcome measures are
decannulation and avoidance of tracheostomy. All cases had improvement of symptoms. Half or 50% of the
patient required repeated balloon dilatations. The paediatric cases successfully avoided tracheostomy while
the adult cases successfully decannulated with no complication from the procedure. Balloon dilatation by
total intravenous anaesthesia coupled with apneic method is a safe and effective method of treatment for
the narrowed airway.
Thyroid carcinoma showing thymic-like differentiation (CASTLE) is a rare malignancy of the thyroid gland, and it accounts for 0.1-0.15% of all thyroid cancers. As the name suggests, it has a histological and immunophenotypic resemblance to thymic carcinoma. Preoperative diagnosis of CASTLE can be difficult as its clinical manifestations, and histological characteristic resembles other aggressive and advanced thyroid carcinomas. It is essential to distinguish CASTLE from other aggressive neoplasms as the former has a more favourable prognosis. Immunohistochemical staining with CD5 can help to differentiate thyroid CASTLE from other aggressive thyroid neoplasms. Due to the rarity of this disease, there is no clear definitive treatment strategy. Surgical resection of CASTLE is usually attempted initially. Nodal involvement and extrathyroidal extension are shown to be the main prognostic factors that influenced the survival of patients. Therefore, complete resection of the tumour is vital to reduce local recurrence rates and to improve the chance of long-term survival. Radiotherapy (RT) for CASTLE is an effective treatment. Curative surgery followed by adjuvant RT should be considered in cases with extrathyroidal extension and nodal metastases. With RT, shrinkage of the tumour and reduction of local recurrence rate is possible. With that in mind, we present a case of CASTLE who presented with airway compression symptoms three years after thyroid surgery. He subsequently underwent tumour debulking surgery and a tracheostomy. The patient refused adjuvant chemoradiotherapy, and during our serial follow-up, he is well and symptom-free.
Introduction: External laryngotracheal (ELT) trauma is rarely encountered in clinical practice. In most
circumstances, this injury is overlooked by the primary attending team. Surgical management of ELT trauma
is complicated, because there is no established management approach for this potentially life-altering, high
morbidity injury. It is important for this injury to be identified early, as any delay in surgical intervention
may result in poor airway and phonatory outcomes. The aim of surgical reconstruction is to minimise the
above debilitating morbidities by restoring the main laryngeal functions as much as possible. Methods: We
reviewed the outcomes of six surgical interventions for ELT trauma at Tengku Ampuan Afzan Hospital from
June 2007 to June 2014. Clinical presentations, computed tomography (CT) scans features, intraoperative
findings, and postoperative outcomes were evaluated. Results: All patients made a good recovery in terms of
phonation except for one patient who had reduced speech function. After one year, one patient was still
dependent on a fenestrated tracheostomy. This article describes the surgical reconstruction techniques used
to achieve these positive outcomes. Stenting is helpful to aid healing and re-epithelialisation. Conclusion:
Prompt recognition and non-traumatised airway control are essential for addressing laryngotracheal trauma.
Subcutaneous emphysema is an important hallmark that should alert the attending physician to the
possibility of ELT trauma. Immediate surgical intervention using appropriate techniques can produce
favorable patient outcomes.
Ludwig angina is a submandibular space cellulitis secondary to oral cavity infection. It is strongly associated with difficult intubation due to limitation in the mouth opening. The presentation of Ludwig angina varies according to the severity of the infection. The extreme presentations include upper airway obstruction and respiratory failure. We present a female teenager with right submandibular abscess as the consequence of Ludwig angina, who was planned for incision and drainage. Successful awake fibre optic intubation was performed as a method of induction due to trismus, deferring the need for tracheostomy.
Acquired cervical aerocele in adults is a rare condition and its delay development after tracheostomy decannulation is reported rarely. Our patient presented eight years after tracheostomy decannulation with a compressible anterior neck mass that only appeared when she coughed and could be deflated using manual compression. The mass was situated suprasternal at the previous tracheostomy scar. Computed tomography scan showed a paratracheal air sac without significant defect at the tracheal wall. Surgical intervention is the best treatment for symptomatic patients. As in this patient, we advise direct laryngoscopy and bronchoscopy for diagnostic and therapeutic purposes in such cases. However, our patient refused any surgical intervention.
Crouzon syndrome (CS) is the most common craniosynostosis syndrome and requires a comprehensive management strategy for the optimization of care and functional rehabilitation. This report presents a case series of 6 pediatric patients diagnosed with CS who were treated with distraction osteogenesis (DO) to treat serious functional issues involving severe orbital proptosis, an obstructed nasopharyngeal airway, and increased intracranial pressure (ICP). Three boy and 3 girls were 8 months to 6 years old at the time of the operation. The mean skeletal advancement was 16.1 mm (range, 10 to 27 mm) with a mean follow-up of 31.7 months (range, 13 to 48 months). Reasonable and successful outcomes were achieved in most patients as evidenced by adequate eye protection, absence of signs and symptoms of increased ICP, and tracheostomy tube decannulation except in 1 patient. Complications were difficult fixation of external stabilizing pins in the distraction device (n = 1) and related to surgery (n = 4). Although DO can be considered very technical and can have potentially serious complications, the technique produces favorable functional and clinical outcomes in treating severe CS.
Bilateral vocal fold immobility (BVFI) is commonly caused by injury to the recurrent laryngeal nerve (RLN) and leads to stridor and dyspnea of varying onsets. A retrospective study was done at the Department of Otorhinolaryngology of Universiti Kebangsaan Malaysia Medical Centre on laser microsurgical posterior cordectomy for BVFI. The objectives were to identify the average duration of onset of stridor from the time of insult and to evaluate the outcome of laser posterior cordectomy as a surgical option. From 1997 to 2007, a total of 31 patients with BVFI were referred for surgery. Twelve patients had tracheostomy done prior to the procedure, whereas 19 patients were without tracheostomy. Ten patients were successfully decannulated, and only 4 patients had complications related to the procedure. The minimum onset of stridor was 7 months, maximum onset of stridor was 28 years, and the mean onset of stridor was 8.7 years. The commonest complication observed was posterior glottic adhesion following bilateral posterior cordectomy. Laser endolaryngeal posterior cordectomy is an excellent surgical option as it enables successful decannulation or avoidance of tracheostomy in patients with BVFI. The onset of stridor took years after the insult to the recurrent laryngeal nerves.
PURPOSE: The aim of this study was to evaluate the narrowing of the trachea in head and neck surgical patients who had undergone elective tracheostomy.
MATERIALS AND METHODS: This is a prospective study. Twenty-five patients were included in this study. All these patients had a preoperative elective tracheotomy, preceding major head and neck surgery for head and neck malignancies. An x-ray of the lateral soft tissue neck was taken after a minimum of 6 weeks after the dissimulation of tracheotomy tube. Diameter of the trachea above the stoma (around 2 cm below the cricoid ring that can be clearly seen in lateral x-ray corresponding to the second tracheal ring) was taken as controls. Data were entered into a computer database and statistically analyzed using SPSS for Windows (version 12.0; SPSS, Chicago, Ill). In addition to descriptive statistics for all patients, inferential statistics were used to compare the 2 tracheal diameters across all patients and within the subgroups of men and women. Associations between outcome and other variables were evaluated statistically using an chi 2 test for the categorical data. Other parametric and nonparametric statistical tests were used when appropriate. Criterion for statistical significance was set at P < .05 (Student t test and 2-tailed test).
RESULTS: From this study, 92% (23/25) patients developed narrowing of trachea, all less than 50%. Very early decanulation of tracheotomy shows low or no narrowing at all. There is gradual narrowing in patients in whom dissimulations were performed after 14 days. Ethnicities of Indian decent (13/25) predominate in this study population. Male patients in this study have shorter decanulation period compared with female.
CONCLUSIONS: Elective surgical tracheotomy is a relatively safe procedure resulting in minimum asymptomatic tracheal stenosis.
Study site: University Malaya Medical Centre, Kuala Lumpur, Malaysia
We describe what we believe is the first reported case of a sublingual hematoma secondary to severe hypertension. The patient, a 77-year-old woman, experienced a spontaneous hematoma of the floor of the mouth, tongue, and sublingual space that eventually caused an airway obstruction. We performed an emergency tracheostomy under local anesthesia and then evacuated the hematoma through an incision along the floor of the mouth. The patient recovered uneventfully.
To illustrate a case of an iatrogenic mucosal tear in the trachea which caused a one-way valve effect, obstructing the airway and manifesting as post-extubation stridor.
Acute stridor is often an airway emergency. We present a valuable experience handling an elderly woman who was initially treated as COVID-19 positive during the pandemic in November 2020. She needed an urgent tracheostomy due to nasopharyngeal (NP) diffuse large B-cell lymphoma causing acute airway obstruction. Fortunately, 1 hour later, her NP swab real-time PCR test result returned as SARS-CoV-2 negative. This interesting article depicts the importance of adequate preparations when handling potentially infectious patients with anticipated difficult airway and the perioperative issues associated with it.
To determine the frequency of stomal recurrence in patients following total laryngectomy in our center and to compare the frequency of previously reported risk factors such as preoperative tracheostomy, subglottic invasion and the level of lymph node metastases, with the rest of the world.
Laryngotracheal separation is a rare variant of laryngeal trauma. However it is life threatening and potentially fatal. Patients with this injury usually succumb at the site of the accident itself. Here we present two cases of laryngotracheal separation of different etiology and of different outcomes. The treatment advocated for laryngotracheal separation is initially airway stabilization followed by formal repair of the transected trachea. However both our cases illustrates that the outcomes can be different and that a long term treatment plan should be individualized to each patient.