Late tracheostomy tube decannulation by progression of a laryngeal tumour: an approach for airway control

Abstract

Malpositions of tracheostomy tubes constitute serious complications. We describe a unique case of insidious dislodgement of the tracheostomy tube from the trachea due to aggressive growth of cancer. We highlight the importance of recognizing this unusual late decannulation and describe an approach for airway management. Written patient consent was obtained for this report. A 59-yr-old male with a T4 N2B laryngeal carcinoma presented for laryngopharyngectomy and free flap reconstruction. He had previously undergone a tracheostomy to relieve airway obstruction. Despite treatment with chemoradiation, the tumour progressed rapidly as evidenced by a computed tomography scan seven months later which showed cancer invading the thyroid, neck musculature, and tracheostomy site. Furthermore, the tracheostomy tube was seen pushed out of the tracheal lumen by progression of the tumour (Figure, Panel A). On the day of surgery, the patient was examined in the holding area. He was not in respiratory distress; his O2 saturation was 97% on room air, and a size 6.0 uncuffed Shiley tube (Tyco Healthcare Group LP, Pleasanton, CA, USA) located in the region of his neck was encased by tumour. Based on physical examination alone, there was no indication to arouse suspicion of decannulation. A new tracheostomy could not be performed below the existing dislodged tube due to tumour covering surface anatomic landmarks of the patient’s neck. Similarly, attempts at awake fibreoptic intubation (following airway topicalization with nebulized lidocaine) were unsuccessful because of diffuse carcinoma obstructing the glottic opening. The decision was made to use the existing tracheostomy site to achieve endotracheal intubation. A flexible fibreoptic bronchoscope was inserted into the Shiley tube, and the tip of the bronchoscope was confirmed to lie outside of the tracheal lumen, partially obstructed by tumour (Figure, Panel B). A path to the trachea was established by carefully advancing the bronchoscope through the gap between the distal end of the Shiley and the tracheal lumen. The scope was then removed and loaded with an Aintree catheter (Cook Incorporated, Bloomington, IN, USA). Bronchoscopy was again performed to insert the Aintree catheter into the airway. Since the tissues around the catheter were friable, a well-lubricated 6.0 reinforced endotracheal tube was chosen for smooth sliding over the catheter as well as for minimizing the possibility of dislodging tumour fragments into the airway, which could occur with forceful advancement of a larger endotracheal tube. With the Aintree catheter securely in place, the Shiley tube was removed, and the endotracheal tube was guided successfully over the catheter into the trachea (Figure, Panel C). General anesthesia was induced after the airway was secured, and the patient’s surgery and postoperative course proceeded uneventfully. Complications related to tracheostomy can be early or late. Decannulation is usually an early event involving a recently placed tracheostomy tube. Four weeks is generally sufficient time for the tracheostomy tract to mature. In contrast, late decannulation is a rare complication since a mature well-formed tracheostomy tract establishes airway patency. When a patient with a tracheostomy presents for surgery, positive pressure ventilation is usually required. This is customarily achieved by removing the Shiley tube and A. Truong, MD (&) D.-T. Truong, MD MD Anderson Cancer Center, Houston, TX, USA e-mail: atruong@mdanderson.org