Tracheal Rupture With Extensive Subcutaneous Emphysema Involving the Face

Abstract

SESSION TITLE: Critical Care SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Tracheal rupture is a rare but life-threatening complication that most commonly occurs after blunt trauma of the neck and chest. Iatrogenic rupture is extremely rare and can occur after intubation, bronchoscopy, or esophagectomy. CASE PRESENTATION: A 51-year-old woman with a past medical history of hypertension presented with facial, neck, and chest wall swelling and crepitus. The patient underwent endoscopic gastric balloon removal one day earlier. 2 days after the procedure, the patient complained of discomfort around her face, neck, and chest. On admission, her examination was notable for palpable crepitus around her scalp, face, orbits, neck, and chest. The chest X-ray showed pneumomediastinum and subcutaneous emphysema (Images A and B). Chest computed tomography (CT) scan of the chest revealed extensive severe subcutaneous, fascial plane, and intramuscular emphysema, involving the scalp, face, neck, and chest (Images C-G, arrow). Additionally, there was diffuse pneumomediastinum extending to the thoracoabdominal junction, and a tear at the posterior tracheal wall. Three-dimensional (3D) CT reconstruction revealed a 5 centimeter posterior tracheal wall tear (Image H). The patient was taken emergently for surgical intervention and repair of the tracheal wall, and recovered fully. DISCUSSION: There are multiple factors which can contribute to tracheal rupture, and they can be divided into mechanical factors that include trauma during intubation, overinflation of the cuff and vigorous coughing, manipulation or surgical intervention within the airway, and anatomical factors. Overinflation of the cuff and sudden movement of the endotracheal tube are the most common causes, while a direct tear caused by the tube itself is rare [1]. Published literature on tracheal rupture has shown a female predominance and mean age over 50 years [2]. This is believed to be due to a weaker pars membranosa in women, as well as a smaller tracheal diameter which makes women more vulnerable to cuff overinflation. Male sex is an independent factor adversely influencing mortality [3]. The clinical manifestations of tracheal injury include subcutaneous emphysema, mediastinal emphysema, pneumothorax, and respiratory distress. They usually appear during surgery or in the immediate post-operative period. Subcutaneous emphysema is the most common symptom and also a protective factor, as its presence alerts to the possible existence of tracheal rupture and accelerates the steps towards its definitive diagnosis and treatment. Diagnostic confirmation is usually made by bronchoscopy. Consensus on the management of tracheal rupture has not yet been reached. Early surgical repair has traditionally been the mainstay of treatment. However, there are now more clinicians who opt for conservative treatment in patients with small ruptures (<2cm), and in selected patients with minimal, non-progressive symptoms. CONCLUSIONS: Tracheal rupture is a very rare condition but it carries a high morbidity and mortality. Diagnostic suspicion is essential, with subsequent confirmation by bronchoscopy. The condition is most common in elderly women, although the risk of death is higher in men. Iatrogenic causes occur most commonly after intubation. Reference #1: Conti M, Pougeoise M, Wurtz A, Porte H, Fourrier F, Ramon P, Marquette CH. Management of postintubation tracheobronchial ruptures. Chest. 2006;130:412-418. Reference #2: Hofmann HS, Rettig G, Radke J, Neef H, Silber RE. Iatrogenic ruptures of the tracheobronchial tree. Eur J Cardiothorac Surg. 2002;21:649-652. Reference #3: Minambres E, Buron J, Ballestros MA, et al. Tracheal rupture after endotracheal intubation. Eur J Cardiothorac Surg. 2009;3:1056-1062. DISCLOSURE: The following authors have nothing to disclose: Radu Postelnicu, Gaetane Michaud No Product/Research Disclosure Information