Airway obstruction from tracheostomy balloon cuff herniation during oral cancer removal. Emergency successfully managed and lessons learnt from device malfunction.

Abstract

Tracheostomy tube cuff balloon herniation is a rare event and can determine airway obstruction. Sometimes the obstruction is not very evident but, if it is not correctly solved, can determine a severe hypoxia with patient's death. We present a 49-year-old male patient, with cT4aN0M0 squamous cell carcinoma of the oral cavity, who was admitted to the hospital for definitive surgical resection. Due to mass an endo-oral intubation was not possible, so a surgical tracheotomy was performed. General anaesthesia was induced with Propofol (2mg/kg) and Fentanil (1 mcg/kg) without gas. Surgery commenced via a trans-oral and trans-cervical approach, but it was halted after approximately 2min as oximetry demonstrated a progressive fall from 98% to 78%. After confirmation of correct function of anaesthetic devices, the endotracheal cannula was tested; although surgeon deflated the tube cuff, repositioned the tube, and re-inflated the cuff, oxygen saturation did not change. So, the cannula was changed and patient's saturation increased up to normal value. The balloon cuff of the cannula showed a herniation, responsible of insufficient ventilation. Cuff herniation should be considered in case of unexpected airway obstruction, and a systematic, rapid approach to investigation and management should ensure timely identification and correction.