Laryngeal Complications of Prolonged Cricothyroidotomy by Misplaced Percutaneous Dilatational Tracheostomy

Abstract

Despite several advantages, percutaneous dilatational tracheostomy (PDT) performed by physicians who are unfamiliar with head and neck anatomy can result in malpractice and cause significant complications although laryngeal complications due to prolonged cricothyroidotomy caused by malpractice PDT have not been reported. Here we report a 64-year-old female who complained of dysphonia while receiving a fenestrated tube. The tube was mispositioned tube caused by malpractice PDT; the tube was placed at the cricothyroid membrane for four months without awareness. To correct subglottic stenosis and vocal cord edema, the patient underwent tracheostomy conversion and suspension laryngomicrosurgery. Although her voice slightly improved after the operation, she was unable to decannulate the tube and developed laryngeal web and subglottic stenosis. To reduce complications, PDT must be performed with accurate knowledge of anatomy