Tracheostomy Site Research Articles

An Unusual Presentation of Supraglottic Low-Grade B-Cell Non-Hodgkin's Lymphoma with Tracheostomal Myiasis.

60-year-old male patient presented with dysphagia and a change in voice for eight months. It was established after Direct laryngoscopy surgery and biopsy, that it was a low-grade B cell non-Hodgkin lymphoma. The primary lesion is resolved with Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisolone regimen. Four months later, patient presented with a discharge and maggots at the tracheostomy site. Ifosfamide, Etoposide, Carboplatin was started after a secondary recurrence of disease progression. Hereby we infer this is an unusual case presentation, myiasis with lymphoma recurrence and tough exacting to the otolaryngologist as there are more chances of misdiagnosing as squamous cell carcinoma..

Assessing Clinical Feasibility and Safety of Percutaneous Dilatational Tracheostomy During Extracorporeal Membrane Oxygenation Support in the Intensive Care Unit

Purpose: A tracheostomy is often used to wean patients off the ventilator, as it helps maintain extracorporeal membrane oxygenation (ECMO) without sedation. A percutaneous dilatational tracheostomy (PDT) performed in critically ill patients is widely accepted, however, its feasibility and safety in ECMO is unclear.Methods: This retrospective observational study included 78 patients who underwent a PDT and ECMO at the surgical intensive care unit (SICU) in a tertiary hospital between January 1, 2016 and December 31, 2019. We analyzed their medical records, including PDT-related complications and clinical variables.Results: The median values of hemoglobin, platelet count, international normalized ratio, partial thromboplastin time, and activated partial thromboplastin time before the tracheostomy were 9.2 (8.5-10.2) g/dL, 81 (56-103) × 103/dL, 1.22 (1.13-1.30), 15.2 (14.3-16.1) seconds, and 55.1 (47.4-61.1) seconds, respectively. No clotting was observed within the extracorporeal circuit, however, minimal bleeding was observed at the tracheostomy site in 10 (12.8%) patients. Of 4 patients with major bleeding, local hemorrhage was controlled in 3 patients, and intratracheal bleeding continued in 1 patient. The mortality rate was 60.9% and 57.1% in the complication and no-complication group, respectively. The durations of SICU stay, hospital stay, and mechanical ventilation were not statistically different between the groups.Conclusion: A PDT performed in critically ill patients was associated with a low rate of bleeding. Complications did not appear to significantly affect the patient outcome. PDT can be performed in patients who usually require a tracheostomy to maintain ECMO.

Management of intrathoracic tracheal stenosis: a challenge

BackgroundTracheal stenosis is a complicated surgical problem, which because of endoscopic techniques can be managed by less invasive procedures. In our case series of three patients with intrathoracic tracheal stenosis following prolonged use of tracheostomy tube, we describe the initial assessment, investigations, management, and post-operative results of the same. In our series, all three patients were tracheostomised (with a metallic tube) for more than 3 months. This resulted in chronic abrasion of intraluminal tracheal mucosa at thoracic level. We managed them with conservative trans-oral and trans-tracheal laser-assisted release instead of open surgeries like trachea-tracheal resection and anastomosis or Crico-tracheal resection and anastomosis.ResultsIn our case series, we chose transoral bronchoscopic fibre laser-assisted release followed by dilatation for one patient and trans-tracheal release for the other two. In the trans-oral case, we faced difficulty in controlling the long length of instruments, thereby effecting the control over the laser tip and precision of cut. During the revision surgery for the same patient, we faced difficulty in securing the airway below the stenosis as it was a low stenosis. In patients 2 and 3, we approached the stenosis site via tracheostomy site, thereby significantly reducing the working length of instruments. This gave us better control over the instruments and we attained better precision in radial incisions. Moreover, if there had been an intraoperative bleeding or aspiration, we could have easily secured the airway by FROVA as distance between stoma and stenosis site was not very long.ConclusionCO2 Lase-assisted stenosis release has a very promising result in up to grade III thoracic tracheal stenosis. A good preplanning with anaesthetists and cardiothoracic surgeons for tailor made approach is a must. Intermittent apnoea technique of anaesthesia really helps in such cases of intrathoracic tracheal stenosis. We advocate to always use soft material tracheostomy tube to prevent mucosal abrasion, to avoid a low tracheostomy without appropriate and to proper fix the tracheostomy tube and try for early decannulation.

Cricotracheostomy in a patient with severe kyphosis: A case report.

Cricotracheostomy is a useful surgical procedure for opening the airway in cases where conventional tracheotomy is difficult. This is a safe and easy technique involving removal of the anterior portion of the cricoid cartilage. Herein, we report the case of a patient with difficulty in neck extension due to severe kyphosis, who underwent cricotracheostomy. A 65-year-old woman developed dyspnea and was transported to our hospital. SpO2 was 60% (room air) and endotracheal intubation was performed. She was managed on ventilator. However, weaning off the ventilator was difficult, and endotracheal intubation was prolonged. Subsequently, the patient was referred to us for a tracheostomy. The patient was unable to maintain the supine position due to severe kyphosis, and computed tomography revealed that the brachiocephalic artery was running just below the thyroid gland. Therefore, conventional tracheostomy was difficult to perform, and we performed cricotracheostomy instead. After the cricotracheostomy, there were no tracheal problems, such as tracheal stenosis and stomal hemorrhage. Cricotracheostomy can be performed in cases where multiple anatomical difficulties may be faced in the tracheostomy site, as in this case. Furthermore, cricotracheostomy is beneficial for long-term airway management because it causes fewer complications compared to conventional tracheotomy.

The feasibility and safety of percutaneous dilatational tracheostomy without endotracheal guidance in the intensive care unit.

BackgroundPercutaneous dilatational tracheostomy (PDT) is a common procedure in intensive care units (ICUs). Although it is thought to be safe and easily performed at the bedside, PDT usually requires endotracheal guidance, such as bronchoscopy. Here, we assessed the clinical outcomes and safety of PDT conducted without endotracheal guidance.MethodsIn the ICU and coronary ICU at a tertiary hospital, PDT was routinely performed without endotracheal guidance by a single medical intensivist using the Griggs technique PDT kit (Portex Percutaneous Tracheostomy Kit). We retrospectively reviewed the electronic medical records of patients who underwent PDT without endotracheal guidance.ResultsFrom January 1 to December 31, 2018, 78 patients underwent PDT without endotracheal guidance in the ICU and coronary ICU. The mean age of these subjects was 71.9±11.5 years, and 29 (37.2%) were female. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 25.9±5.8. Fifty patients (64.1%) were on mechanical ventilation during PDT. Failure of the initial PDT attempt occurred in four patients (5.1%). In two of them, PDT was aborted and converted to surgical tracheostomy; in the other two patients, PDT was reattempted after endotracheal reintubation, with success. Minor bleeding at the tracheostomy site requiring gauze changes was observed in five patients (6.4%). There were no airway problems requiring therapeutic interventions or procedure-related sequelae.ConclusionsPDT without endotracheal guidance can be considered safe and feasible.

Tracheostomy Outcomes in COVID-19 Patients in a Low Resource Setting.

COVID-19 predominately affects safety net hospitals. Tracheostomies improve outcomes and decrease length of stay for COVID-19 patients. Our objectives are to determine if (1) COVID-19 tracheostomies have similar complication and mortality rates as non-COVID-19 tracheostomies and (2) to determine the effectiveness of our tracheostomy protocol at a safety net hospital. Patients who underwent tracheostomy at Los Angeles County Hospital between August 2009 and August 2020 were included. Demographics, SARS-CoV-2 status, body mass index (BMI), Charlson Co-morbidity Index (CCI), length of intubation, complication rates, decannulation rates, and 30-day all-cause mortality versus tracheostomy related mortality rates were all collected. Thirty-eight patients with COVID-19 and 130 non-COVID-19 patients underwent tracheostomies. Both groups were predominately male with similar BMI and CCI, though the COVID-19 patients were more likely to be Hispanic and intubated for a longer time (P = .034 and P < .0001, respectively). Both groups also had similar, low intraoperative complications at 2% to 3% and comparable long-term post-operative complications. However, COVID-19 patients had more perioperative complications within 7 days of surgery (P < .01). Specifically, they were more likely to have perioperative bleeding at their tracheostomy sites (P = .03) and long-term post-operative mucus plugging (P < .01). However, both groups had similar 30-day mortality rates. There were no incidences of COVID-19 transmission to healthcare workers. COVID-19 tracheostomies are safe for patients and healthcare workers. Careful attention should be paid to suctioning to prevent mucus plugging. 3.

A strategy to prevent tracheo-innominate artery fistula in the course of laryngotracheal separation: 9-year experience in a children's hospital

Aim of the studyLaryngotracheal separation (LTS) is known to be the definitive solution for intractable aspiration pneumonia in neurologically impaired children. Postoperatively, a tracheostomy cannula is usually required. However, there are fatal cannula related complications such as a tracheo-innominate artery fistula (TIAF). We present our methods of preventing TIAF. MethodsA retrospective review in a single center from 2011 to 2019 identified 57 cases treated with LTS. We divided them into three groups: no pre-existing tracheostomy (n = 26), pre-existing tracheostomy with preservation of the pre-existing fistula (n = 20), and pre-existing tracheostomy without preservation of the pre-existing fistula (n = 11). The first group underwent traditional modified Lindeman's procedure. The second received transection of the trachea above the tracheostomy site, while the third had transection of the trachea at the tracheostomy site and creation of a distal end tracheostomy. Proper length and the angle of the cannula were selected to prevent damaging the innominate artery by the tip of the cannula. If the innominate artery compressed the trachea anteriorly, prophylactic arterial transection was considered. ResultsThree patients (5.3%) died from causes unrelated to the surgical treatment. Only one patient had a postoperative TIAF followed by LTS (1.8%). Other postoperative complications were: wound infection (8.8%), intratracheal granuloma (12.3%), intratracheal minor bleeding (10.5%), wound granuloma (43.9%), leakage (1.8%). No one required revision of LTS. ConclusionSuccess rates of LTS were high without major complications in all three groups and implies a safe operation and a definitive solution to intractable aspiration.

Tracheoinnominate Artery Fistula.

This simulation provides training for emergency medicine residents in the stepwise management of a patient who presents with bleeding from a tracheoinnominate artery fistula. Additional learners who might benefit from this simulation are otolaryngology and general surgery residents as well as critical care fellows. Hemorrhage from a tracheoinnominate artery fistula (TIAF) is a rare but life-threatening complication in a patient with a recent tracheostomy. This complication occurs in 0.7% of tracheostomy patients with a mortality of 50-70%.1 Seventy-five percent of patients with a TIAF will present within the first three weeks of surgery and 50% of patients will present with a sentinel bleed that briefly resolves.1 Key elements of a history and exam that should raise a provider's concern for this diagnosis include a recent tracheostomy (within the last 4 weeks), a percutaneous tracheostomy, prior radiation, chronic steroid use, a neck or chest deformity or a sentinel bleed.2 Survival from a TIAF hinges upon emergent, operative repair by an otolaryngologist and cardiothoracic surgeon. Cuff hyperinflation and the Utley Maneuver are critical bedside interventions to temporize this massive bleed and stabilize the patient for definitive, operative repair. By the end of this simulation, learners will be able to: 1) perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site, 2) describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF, 3) demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver, 4) verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above, 5) demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol. This case was written with a modified, low-fidelity manikin, traditionally used for training in nasogastric tube placement and tracheostomy care. We modified this manikin to simulate a hemorrhage from the tracheostomy site.3 The patient in our case had a history of laryngeal cancer, and thus we occluded his larynx for this simulation. As a result of this obstruction, he was unable to be intubated from above. We provided confederates, a bedside nurse and family member, to assist the learners throughout the case. We also utilized a simulation technician to operate dynamic vital signs on a simulated cardiac monitor. It would be technically challenging to adapt this case to a high-fidelity simulator due to potential for damage of the internal electrical elements by the large amount of artificial blood from the tracheostomy tube. However, a mechanical pump provided a useful means of active bleeding in this low-fidelity manikin. We provided a pre- and post-simulation questionnaire for the 33 emergency medicine residents who participated in this simulation. There were 11 residents from each of the PGY-1, PGY-2 and PGY-3 year-groups. Thirty-two residents (97%) completed the pre-survey and 33 residents (100%) completed the post-survey. For our questions, we used a 5-point Likert Scale to assess a resident's knowledge of the learning objectives within this simulation. Responses from our pre- and post- survey indicated a significant improvement in knowledge about a tracheoinnominate artery fistula as well as the general management of tracheostomy complications in the emergency department. This simulation is a useful educational tool for instructing emergency medicine residents on optimal management of tracheostomy emergencies such as a TIAF. The interprofessional teaching by an emergency medicine attending and mid-level (PGY-3) otolaryngology resident allowed for a richer and more detailed discussion during the debriefing. Throughout the case, the emergency medicine attending played the role of a bedside nurse and offered supportive, clinical cues when bleeding recurred. The otolaryngology resident played the role of a family member and offered helpful cues during the history and exam portion of the case. Following the case, both content experts provided useful clinical insight during the debriefing. If staffing availability permits, it might be advantageous to use additional simulation-trained personnel to play the roles of the nurse and family member, thus allowing the emergency medicine attending and otolaryngology content experts to simply view the case from the control room and perform the debriefing. Tracheostomy, surgical airway, tracheoinnominate artery fistula, bleeding from tracheostomy site, complications with tracheostomies, hemorrhagic shock.

Modified Manikin for Tracheoinnominate Artery Fistula.

This simulator is designed to instruct emergency medicine residents in tracheostomy training that involves bleeding from the tracheostomy site. Any resident, fellow, or attending physician who cares for patients with complications from their tracheostomy might benefit from this innovation. The emergency medicine provider must maintain proficiency in caring for patients with complications from their tracheostomy. In the United States, over 110,000 patients receive tracheostomies per year.1 A rare but catastrophic complication of tracheostomies, usually within the first month of placement, is a tracheoinnominate artery fistula (TIAF). This complication occurs in 0.7% of tracheostomy patients and carries a 50-70% mortality.1,2 We modified a low-fidelity tracheostomy manikin to instruct learners in the stepwise management of hemorrhage from a TIAF. By the end of this educational session, learners will be able to:Perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site.Describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF.Demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver.Verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above.Demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol. This modified manikin is a useful training tool for any healthcare provider who is involved in the treatment and stabilization of a variety of tracheostomy emergencies, from bleeding to infection to obstruction or dislodgement. Our case was presented on two separate occasions, to otolaryngology interns (PGY-1), and emergency medicine residents (PGY 1-3). It involved the care of a patient with a sentinel bleed and subsequent hemorrhage from a tracheoinnominate artery fistula (TIAF). This low-fidelity tracheostomy manikin provides the ideal platform for any complex, tracheostomy case, particularly where ongoing bleeding from the tracheostomy site might permanently damage the electrical circuitry of a high-fidelity model. We initially fashioned this modified manikin for tracheostomy training during a simulation "boot camp" for otolaryngology PGY-1 residents. Our use of this modified manikin for tracheostomy training was a useful teaching tool during our otolaryngology intern "boot camp." As a result, we organized a subsequent simulation training session with our PGY 1-3 emergency medicine residents to provide similar instruction in management of a TIAF. We provided a pre- and a post-simulation survey for the 33 emergency medicine residents who participated in the TIAF simulation with our modified tracheostomy manikin. There were 11 residents from each of the PGY-1, PGY-2, and PGY-3 year-groups. Thirty-two residents (97%) completed the pre-simulation survey, and 33 residents (100%) completed the post-simulation survey. We used a 6-point Likert Scale from "strongly agree" to "strongly disagree" to assess a resident's knowledge of multiple learning objectives within this simulation. The pre- and post-simulation survey supported this simulation and manikin innovation as a useful teaching tool for tracheostomy emergencies such as a TIAF. This was a useful innovation for emergency provider training in the recognition and management of a TIAF, a rare but emergent tracheostomy complication. In addition to this bleeding complication, this innovation might be useful for a variety of tracheostomy emergencies such as site infection, obstruction, and tube dislodgement. We highly recommend the involvement of both an emergency medicine and otolaryngology content expert in the design and debriefing of tracheostomy cases with this modified manikin. In our experience, a facilitated debriefing by an experienced clinician and educator from both fields provided a diverse perspective for challenging cases such as bleeding from a TIAF. Difficult airway, tracheostomy, tracheoinnominate fistula, hemorrhagic shock, tracheostomy complications, Utley Maneuver.

Gold Standard? Method of Citric Acid Solution Swallowing Test as a Screening Test for Patients with Tracheostomy.

This study aimed to apply various ranges of citric acid levels in the mouth and T-cannula to compare the validity with instrumental aspiration measures in patients with tracheostomy. Sixty-one patients underwent the citric acid cough reflex test (CRT) and videofluoroscopic swallowing study (VFSS). Citric acid was delivered via facemask and T-cannula at concentrations of 0.4mol/L, 0.6mol/L, and 0.8mol/L. Further, we recorded the coughing count and presence of ≥ 2 (C2) and ≥ 5 (C5) coughs. CRT via facemask at 0.4mol/L C2, 0.6mol/L C5, and 0.8mol/L C2 and C5 were significantly associated with the presence of tracheal aspiration during VFSS. The sensitivity and specificity were optimized at 0.8mol/L C2 for mouth inhalation and at 0.8mol/L C5 for T-cannula inhalation. There was a significant difference in the coughing count during CRT at 0.4 mol/Land 0.8 mol/Lvia mouth inhalation between patients with or without tracheal aspiration, but not via T-cannula. The AUC for 0.8mol/L facemask inhalation was 0.701. The optimal cut-off value of coughing count was thrice with 84.62% sensitivity and 50.00% specificity on the ROC curve. Afferent sensory nerve desensitization around and below the tracheostomy site could affect coughing reflex initiation and decrease the sensitivity of detecting aspiration in tracheotomized patients. The citric acid CRT via facemask can reliably detect tracheal aspiration and presence of coughing reflex compared to that via T-cannula in patients with tracheostomy.

A Case of Tracheal Granuloma Removal using Potassium-Titanyl-Phosphate Laser

Tracheal granuloma, the most commonly reported sequela of pediatric tracheotomy. A variety of techniques are available for the management of tracheal granuloma. Potassium-titanyl-phosphate (KTP) laser has been previously established as an acceptable technique for removal of laryngeal surgery, which emits a green light with a wave length of 532 nm, which is well-absorbed by hemoglobin and can coagulate and vaporize tissue. The ability to deliver laser energy through a flexible glass fiber makes the technique convenient for use with a rigid bronchoscope, overcoming problems with intraluminal access encountered with earlier attempts at CO2 laser therapy for this problem. Another advantage of KTP laser is the avoidance of the risks and morbidity associated with an open procedure. We report our surgical technique KTP laser in the management of tracheal granuloma removal into the tracheostomy site. KTP laser is good tool for management of tracheal granuloma with low incidence of complications. Key words: Trachea ㆍ Granuloma ㆍ KTP laser 핵심용어: 기관 ㆍ ìœ¡ì•„ì¢ ã† KTP ë ˆì´ì €

Tracheostomy in Patients on Venovenous Extracorporeal Membrane Oxygenation: Is It Safe?

The anticoagulation and coagulopathy associated with venovenous extracorporeal membrane oxygenation (VV-ECMO) lead to concern for increased risks of tracheostomy. The purpose of this study is to evaluate the safety of tracheostomy in patients on VV-ECMO. Patients admitted between November 2015 and January 2019 to a dedicated intensive care unit for VV-ECMO were reviewed retrospectively. 96 patients underwent tracheostomy. Tracheostomy was performed percutaneously in 51 patients, open in 24, and hybrid in 21. 28 patients had postprocedure bleeding which was from the tracheostomy site in 13, the airway in 13, and both in 2. 6 patients had major tracheostomy site bleeding and 3 patients had major airway bleeding. 7 patients had minor tracheostomy site bleeding, 10 patients had minor airway bleeding, and 2 patients had minor bleeding at both. Bleeding complications were more common following percutaneous tracheostomy. Being on anticoagulation prior to tracheostomy was protective. Bleeding following tracheostomy in VV-ECMO is common with higher bleeding rates observed for those done percutaneously. Most complications were minor. Tracheostomy in patients on VV-ECMO appears safe.

RARE GENETIC DISORDER: HEREDITARY ANGIOEDEMA TYPE 1

SESSION TITLE: Medical Student/Resident Allergy and Airway Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hereditary Angioedema is a rare genetic disorder characterized by recurrent episodes of angioedema without pruritus or urticaria, affecting the skin or mucosal tissues of the upper respiratory and GI tract. This is caused by a mutation in the SERPING1 gene, resulting in deficiency (type I) or dysfunction (type II) of C1 inhibitor protein. CASE PRESENTATION: A 43-year-old female with PMH of recurrent episodes of angioedema requiring intubation was admitted due to chief complaint of facial angioedema, hand and feet swelling associated with dyspnea, and stridor. Due to acute respiratory failure, emergent cricothyrotomy was attempted multiple times, and eventually open tracheostomy was performed and she was placed on mechanical ventilation. Simultaneously, the patient received dexamethasone, epinephrine, and famotidine. Work up revealed low levels of C1 inhibitor and C4, consistent with bradykinin-mediated hereditary angioedema type I. Rapid weaning from mechanical ventilation to a venturi mask was achieved. Her tracheostomy tube was changed to a Montgomery long-term cannula. Later, the Montgomery tube was changed to a #6 cuffless due to hemoptysis and posterior tracheal wall irritation. Her hospital course was complicated with supraglottic edema and grade 1 subglottic stenosis treated with subglottic balloon dilation and steroid Kenalog injection. Broad-spectrum antibiotics were administered due to purulent drainage around the tracheostomy site and thick sputum concerning for tracheobronchitis. The patient had significant improvement and was successfully capped. Due to exorbitant cost and limited insurance long term prophylaxis with Takhzyro (Lanadelumab), and Icatibant was not possible. She was started on Danazol 200 mg daily with 2 rescue doses of Takhzyro SC, 6 rescue doses of icatibant 30 mg SC, and EpiPen for respiratory distress. She was counseled to avoid any NSAIDs, ACEI, tamoxifen, and was discharged to another facility for rehabilitation and decannulation. DISCUSSION: This is a case describing a rare genetic disease, with a mortality rate of 30% due to asphyxiation from laryngeal edema that accounts for less than 1% of all the angioedema episodes. Laryngeal swelling usually develops around several hours (mean of 7h). There are 3 phases: predyspnea, dyspnea, and loss of consciousness phase ending with death; with an average length of 3.7h, 41 minutes, and 9 minutes respectively. CONCLUSIONS: Early diagnosis and education are paramount in these patients, to receive long term prophylaxis as C1 inhibitor concentrate, monoclonal antibody to kallikrein (lanadelumab), attenuated androgens; avoiding exacerbating factor; and being prepared for acute attacks with the same agents. Reference #1: .https://www.haea.org/assets/img/2013Recommendations.pdf Reference #2: Uptodate hereditary angioedema DISCLOSURES: No relevant relationships by Karim Anis, source=Web Response No relevant relationships by Lady Sanchez Fernandez, source=Web Response

A RARE CASE OF CERVICAL HARDWARE MIGRATION CAUSING ESOPHAGEAL PERFORATION

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Esophageal perforation caused by migration of cervical hardware in the delayed setting is a rare but deadly complication of anterior cervical spine surgery (ACSS). Esophageal perforation is a known complication of ACSS, which accounts for more than 40% of documented cases. However only 0.2-1.5% of those cases happened in the delayed setting and the initial presentation can be atypical. The purpose of this report is to highlight the importance of promptly diagnosing these patients and moving forward with the appropriate management. CASE PRESENTATION: 32-year-old man with a PMH of C6 spinal cord injury 3 years prior with residual quadriplegia requiring anterior cervical discectomy and fusion (ACDF) of C6-T1 with C7 corpectomy and a tracheostomy. He presented with worsening abdominal pain. Imaging and colonoscopy were both normal so an EGD was performed which found an eroded foreign body in the lumen of the proximal esophagus. Neurosurgery was consulted and ordered CT imaging which confirmed our suspicion. A bronchoscopy was then done to evaluate his tracheostomy site which did not appear to have any effect on his airway nor were any fistulas observed. Despite the aforementioned findings the patient was clinically stable and denied any dysphagia, odynophagia, poor appetite, or irregular bowel movements. Patient is currently scheduled for cervical spine hardware revision. DISCUSSION: ACDF has been around since the 1950s, is well documented, and has an overall complication rate of 5%. That being said, surgical complications including perforation can be further subdivided into acute or delayed (>30 days post-op) and can range from local infection to mediastinitis and death. While most acute perforations during or after ACSS are iatrogenic, the majority of delayed perforations are from hardware failure (41%) which come from loosened or migrated screws/plates. Chronic erosion of hardware makes up 31% of cases and is thought to be caused by tissue ischemia from the prolonged pressure of cervical hardware, thus weakening the posterior esophageal wall leading to deadly complications. Esophageal perforation in this subset of patients can happen during ACSS or up to 11 years post-operatively in some studies. Obtaining a pertinent history is paramount in the settings of acute versus chronic esophageal perforations. An acute perforation would present with dysphagia and odynophagia (54%), fever (21%), and/or neck swelling (21%). Our case is atypical in that our patient was being worked up for something entirely different and denied any of the aforementioned signs and symptoms. CONCLUSIONS: Delayed esophageal erosions require a high level of suspicion as presenting signs and symptoms may be nonspecific. Operative interventions with revision of cervical spine surgery and myofascial repair are the standard of care for this condition with considerations being made for comorbidities and clinical circumstances. Reference #1: S. H. Halani, G. R. Baum, J. P. Riley et al., “Esophageal perforation after anterior cervical spine surgery: a systematic review of the literature,” Journal of Neurosurgery: Spine, vol. 25, no. 3, pp. 285–291, 2016. Reference #2: A. Marquez-Lara, S. V. Nandyala, H. Hassanzadeh, M. Noureldin, S. Sankaranarayanan, and K. Singh, “Sentinel events in cervical spine surgery,” The Spine Journal, vol. 39, no. 9, pp. 715–720, 2014. Reference #3: D. Yin, X. Yang, Q. Huang et al., “Pharyngoesophageal perforation 3 years after anterior cervical spine surgery: a rare case report and literature review,” European Archives of Oto-Rhino-Laryngology, vol. 272, no. 8, pp. 2077–2082, 2015. DISCLOSURES: No relevant relationships by Zaid Ansari, source=Web Response No relevant relationships by MAYKEL IRANDOST, source=Web Response No relevant relationships by Tyler Putnam, source=Web Response No relevant relationships by Ali Saeed, source=Web Response

S2757 Vitamin K Deficiency in the Setting of Long-Term Blenderized Tube Feeds in a Teenager

INTRODUCTION: Severe, symptomatic presentation of nutritional deficiencies are uncommon in the current era. Vitamin K deficiency is classically seen in newborns and can present as early as 24 hours after birth and as late as up to 6 months. However, in pediatric patients with chronic comorbidities, vitamin K deficiency can also occur later in life with risk factors such as enteral feeding and recent antibiotic use. We describe a case of acquired vitamin K deficiency in a teenager on long term enteral nutrition. CASE DESCRIPTION/METHODS: A 17-year-old male with spinal muscular atrophy type 1, ventilator, and gastrostomy tube dependence, was admitted for coagulopathy noted during routine follow up after a diarrheal illness. He was treated with a short course of metronidazole for suspected small intestinal bacterial overgrowth as stool pathogens were negative. Physical examination revealed oozing from an anal fissure, tracheostomy, and gastrostomy sites. Laboratory studies revealed a prothrombin time (PT) of 114 s (normal: 9.4-12.5 s), partial thromboplastin time (PTT) 99.2 s (normal: 25.1-36.5 s) and international normalized ratio (INR) of 9.5 (normal: 1.1 or below). Fibrinogen and D-dimer were normal, ruling out disseminated intravascular coagulation. Factors V were normal at 94%, VIII more than 150%, VII low at 3%, and IX low at 11%. Mixing studies revealed deficiencies of the intrinsic and extrinsic pathways, and this, coupled with low factors VII and IX confirmed vitamin K deficiency. He received parenteral vitamin K which resolved his coagulopathy - PT 13.2 seconds, PTT 37.1 seconds, and INR of 1.2. His blenderized tube feeding regimen consisted of a base of Vivonex® Pediatric® mixed with baby foods and juice. This formulation did not meet the Dietary Reference Intake for vitamin K (44.2mcg/dL, recommended is 60-75mcg/dL), protein, phosphorus, calcium, zinc, folate, and essential fatty acids. He was discharged home on supplemental vitamin K, a multivitamin, protein supplement and, safflower oil. DISCUSSION: Our case highlights an important, yet frequently unrecognized differential of coagulopathy: vitamin K deficiency. This could be asymptomatic until the patient develops a bleeding diathesis. Clinicians should be aware that for pediatric patients on long-term blenderized tube feeds, it is essential to monitor micro and macronutrients on a regular basis.

Anesthetic Management for Emergent Repair of Tracheoinnominate Fistula

We present a case of a 30-year-old female, who had tracheostomy revision complicated by false passage into the subcutaneous space and pneumothorax. Six days later, she developed massive bleeding from the mouth, nose, and tracheostomy site. Approximately 2 liters of blood was lost. With high suspicion for tracheo-innominate fistula, she was emergently brought to the operating room for fistula repair. Her anesthetic management was initially focused on maintaining spontaneous ventilation with inhalation agents until surgical exposure was adequate. An endotracheal tube was then placed under guidance of a video-laryngoscope. The tracheostomy tube was then removed over a Cook catheter to maintain secure passage in case of airway collapse. The oral endotracheal tube was then inserted distal to the arterial and tracheal defect. The patient's bleeding was stopped, the fistula was repaired, and she was transferred back to the intensive care unit, but she died several days later due to multi-organ failure.

Tracheal Stenosis after Tracheostomy

INTRODUCTIONTracheal stenosis is a late and usually non-life threatening complication of surgical and percutaneous tracheostomies (PDT) as well as delayed endotracheal extubation. METHODSWe undertook a retrospective review of all patients who underwent a surgical tracheostomy over a 10 year period. Patients were included in the study if they had CT or MRI imaging of the tracheostomy site both pre-operatively and six or more weeks post operatively. Patients whose imaging was not available were excluded (n = 3) as were those patients who still had a tracheostomy in situ (n = 8). In total 91 patients were included in the study. In the same period 1170 surgical tracheostomies were performed by the maxillofacial surgeons. The images were analysed by a radiologist and the degree of stenosis reported. RESULTSAll 91 patients underwent a tracheostomy with a window. 83 patients did not demonstrate any stenosis. Looking at the remaining 8 patients with stenosis: 6 patients had stenosis of less than 25%, 1 patient had stenosis between 25-50% and 1 patient had stenosis greater than 50%. Both patients with stenosis greater than 25% had more than one surgical tracheostomy. CONCULSIONWe have shown that the risk of stenosis is 8.8%, lower than often quoted in literature, and when it occurs it is likely to be symptomatic only in severe stenosis. Our main risk of stenosis was repeat surgical tracheostomies which also seems to be linked to a greater degree of stenosis.

A RETROGRADE STUDY OF MYIASIS IN A TERTIARY CARE CENTRE

Myiasis in head and neck region is a rare occurrence and is usually found in tropical countries like India. Poor hygiene, unsanitary living conditions, mental retardation, neglected wounds, diabetes mellitus and old age along with a warm and humid climate lay down a conducive environment for the larva of dipterous fly to infest humans. Maggots due to their tissue destructive properties can affect many regions in otolaryngorhinology like nasal cavity, ears, oral cavity, tracheostomy site ostoma, PNS, the skin and ulcerative lesions of head and neck. The burden of the disease lies in the fact that the complications range from minor tissue destruction, perforation of either the tympanic membrane, palate or septum, vertigo, angioedema to severe neurological manifestations, intracranial extension or rarely even death. Objective: To assess the commonly affected age group and gender infested by myiasis, it’s seasonal trend, socioeconomic status of the affected patients and the relationship of myiasis infestation with various predisposing factors. Methodology: Retrograde study was conducted on 95 patients of department of otorhinolaryngology. The study was done from January 2015 to October 2018 by collecting data of 3 years 10 months time interval and results tabulated. Ethical clearance was sort and patients consent obtained. Result: The most commonly affected age group was found to be elderly, in the 7th decade of life (56.84%). Females were more commonly affected than males consisting of 55 out of 95 cases (57.89%), with a male female ratio of 1:1.4. Majority of cases presented in the months of October-January, with a peak in November (32/95). Nasal myiasis was found to be more common (69 cases) in comparison to aural and oral cavity myiasis. The most common predisposing factor was found to be Atrophic Rhinitis in 66.7% cases. Conclusion : With awareness and improved personal hygiene a devastating disease like myiasis is easily preventable and curable.

Effect of low or high doses of low‐molecular‐weight heparin on thrombin generation and other haemostasis parameters in critically ill patients with COVID‐19

The clinical picture of the coronavirus 2 (SARS-CoV-2)/COVID-19-related acute respiratory syndrome is often associated with a coagulopathy. An elevated D-dimer has been linked with an unfavorable prognosis in COVID-19 patients.

Current scenario of tracheostomy: our experience

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Tracheostomy is an important surgical procedure done by ENT surgeons. In this study we have assessed the indications and complications encountered during tracheostomy and decannulation.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 100 patients undergoing tracheostomy by the Department of Otolaryngology and Head and Neck Surgery between 1st January and 31st December 2015 in a tertiary care hospital in Central India were included in the study. The various indications of tracheostomy along with the complications encountered and decannulation following tracheostomy were studied. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In this study, most commonly (22%) tracheostomies were performed in young (31-40) years, male (73%) patients. This included 79% elective and 21% emergency tracheostomies. The indications of tracheostomy were retained secretions 61%, laryngopharyngeal obstruction 21%, and respiratory insufficiency 19%. 21 intra-operative complications included bleeding (18% cases) and apnoea (3% cases). Wound infection 19%; subcutaneous emphysema 10%; tube block 6% and haemorrhage 2% constituted 37 immediate post-operative complications. 17 late post-operative complications included stoma stenosis 9%; granuloma formation 4% and trachea-oesophageal fistula and aspiration 2% each. 33% of total patients were decannulated easily.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; In conclusion we found that elective tracheostomy is associated with lower morbidity and mortality and strapping of tracheostomy site is an easy, safe and effective method of tracheostomy closure in properly selected patients.&lt;/p&gt;