Urgent Tracheostomy Research Articles

Risk factors for postoperative bleeding after thyroid surgery

Postoperative bleeding after thyroid surgery is a feared and life-threatening complication. The aim of the study was to identify risk factors for postoperative bleeding, with special emphasis on the impact of the individual surgeon and the time to diagnosis of the complication. Data on consecutive thyroid operations were collected prospectively in a database over 30 years and analysed retrospectively for potential risk factors for postoperative bleeding. There were 30,142 operations and postoperative bleeding occurred in 519 patients (1·7 per cent). Risk factors identified were older age (odds ratio (OR) 1·03 per year), male sex (OR 1·64), extent of resection (OR up to 1·41), bilateral procedure (OR 1·99) and operation for recurrent disease (OR 1·54). The risk of complications among individual surgeons differed by up to sevenfold. Postoperative bleeding occurred in 336 (80·6 per cent) of 417 patients within the first 6 h after surgery. Postoperative bleeding was diagnosed after 24 h in ten patients (2·4 per cent), all of whom had bilateral procedures. Nine patients required urgent tracheostomy. Three patients died, giving a mortality rate of 0·01 per cent overall and 0·6 per cent among patients who had surgery for postoperative bleeding. Observation for up to 24 h is recommended for the majority of patients undergoing bilateral thyroid surgery in an endemic goitre area. Same-day discharge is feasible in selected patients, especially after a unilateral procedure. Quality improvement by continuous outcome monitoring and retraining of individual surgeons is suggested.

Conservative approach to the isolated cricoid cartilage fracture

Isolated cricoid fracture is encountered rarely during the clinical follow-up. A 71-year-old female patient was referred to emergency service with complaints of fall from height, and urgent tracheotomy was performed due to dyspnea. During the examination, isolated fractures of the cricoid cartilage were identified. With the conservative approach, the patient remained symptom-free and was discharged after decannulation.

Tracheal agenesis: Respiratory distress, aphonia and emergency airway management

Tracheal agenesis is an extremely rare, usually fatal, congenital anomaly presenting with respiratory distress and aphonia. We present a case of tracheoesophageal fistula, in which an endotracheal tube failed to be placed; alternatively the infant was partially venitlated via an endoesophageal tube. A delayed transfer of the infant and inability to perform an urgent tracheostomy led to the infant's demise. Floyd described 3 different phenotypes of tracheal agenesis. The anomaly is thought to be due to errors in development occurring during the division of the foregut into the esophagus and the trachea. Affected neonates uniformly present in the immediate postnatal period with severe respiratory distress and aphonia. Endotracheal intubation is difficult, often with multiple failed attempts and inability to advance the tube below the vocal cords. Ventilation with a tube placed in the esophagus can temporarily sustain life in the presence of a fistula as in this case. The condition can occur in isolation or in association with malformations in organ systems other than the lungs, airway and esophagus. New approaches for reconstruction of the trachea have been reported and regenerative medicine may have a future role.

Laryngeal dystonia in the course of multiple system atrophy: a cause of postoperative respiratory insufficiency

Multiple system atrophy (MSA) is an adult onset, incurable neurodegenerative disease, characterized by symptoms of nervous system failure. Occurrence of laryngeal dystonia indicates increased risk of sudden death caused by airway occlusion. We present the case report of 63-year-old patient with history of orthostatic hypotension, parkinsonism, progressive adynamia, and stridor. The patient was admitted to the hospital for diagnosis of orthostatic hypotension. A diagnosis of possible MSA was made. Because of patient’s complaints, an X-ray of the hip joint was taken. It revealed femoral neck fracture. Endoprosthesis insertion under general anesthesia was performed. Two days later the patient presented progressive adynamy and respiratory insufficiency. Endotracheal intubation and respiratory support were required followed by extubation and one more intubation. After second extubation, stridor and acute respiratory insufficiency occurred. Urgent tracheostomy was performed. After 13 days in ICU, the patient was discharged to the rehabilitation center.

“Glandular intoxication” following emergent tracheotomy during transsphenoidal surgery for acromegaly: Cushing’s 1910 unrecognized case of thyroid storm?

Harvey Cushing's monograph The Pituitary Body and Its Disorders describes Case XXXVIII, H. M. B., a 33 year-old man who presented with acromegaly in 1910. The detailed operative note reports an emergency tracheotomy performed following induction of anesthesia, and immediately prior to a naso-labial approach to a suspected sellar lesion. Cushing's post-operative notes document a significant increase in temperature prior to the patient's death. Cushing offered an explanation for the patient's symptoms immediately pre-mortem, which is largely unsatisfying. Following institutional review board approval, and through the courtesy of the Alan Mason Chesney Archives, the surgical records from the Johns Hopkins Hospital, 1896-1912, were reviewed. A review of the original surgical file revealed a more extensive description of the emergent tracheotomy required following induction of anesthesia, and provided additional information regarding the patient's symptoms in the immediate pre-mortem period. Namely, the urgent tracheotomy transected the thyroid gland, and post-operatively the patient experienced significant tachycardia and hyperthermia, consistent with thyroid storm. The new information regarding the hospital course of H. M. B. offers insight into the previously incompletely described circumstances surrounding his emergent tracheotomy, and subsequent death. Additionally, the case underscores the clinical importance of recognizing and appropriately treating thyroid storm.

緊急気管切開術を要したポリープ様声帯の 1 例

緊急気管切開術を要したポリープ様声帯の 1 例

Stridor as initial clinical presentation of tracheal chondroma

Chondromas are benign cartilaginous tumours that are uncommon in the head and neck region. Only few cases of chondroma have been reported in the trachea. We present a 70-year-old patient who presented clinically with severe dyspnoea requiring urgent tracheotomy. An oval, expansive, well-delineated tracheal tumour was evident on magnetic resonance imaging. The mass was removed surgically in its entirety, preserving tracheal rings, and the histopathological diagnosis was chondroma. The patient was decannulated after 2 months, and was followed for 3 years. Urgent tracheotomy is an unusual initial clinical manifestation of this infrequent tumour. Surgical options and the choice of therapy in this case are discussed.

緊急気管切開術を要した喉頭真菌症の１例

A Case of Laryngeal Fungal Infection that required an urgent tracheotomy was reported. A 69-year-old male was referred to our hospital complaing of difficulty with breathing. A mass lesion was detected on his left false cord. Ground-glass opacity in the bilateral lower lobes showed up on a chest X-ray image. A biopsy utilizing a laryngeal fiberscope was performed. The histopathological diagnosis was revised to hyperkeratosis with a fungal infection. Therapy was initiated with polyconazole (400mg/day) for 16 days and the pulmonary mycosis disappeared completely, however, the fungal infection of the larynx remained unchanged. At day 27 after therapy with polyconazole, he had serious difficulty in breathing. Swelling of the larynx and an upper airway obstruction was found. An urgent tracheotomy was done. The patient was treated by intravenous drip of micafungin, and an almost complete remission was achieved within two months.

A Case of Bilateral Vocal Cord Paralysis in a Patient with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting the synovial membrane and causing joint damage and bone destruction. The symptoms of cricoarytenoid joint (CJ) arthritis often include hoarseness, and a sense of pharyngeal fullness in the throat. Sometimes, in cases with bilateral CJ involvement, an urgent tracheostomy might be required for acute airway obstruction. In this report, we describe a 45-years-old man suffering from voice change and aspiration due to hampered adduction of the vocal fold that was caused by RA with bilateral CJ involvement. The medication treatment for RA was carried out and the patient retrieved her normal voice after one month. � Korean J Otorhinolaryngol-Head Neck Surg 2011;54:235-8 Key WordsZZVocal cord paralysis ㆍArthritis ㆍRheumatoid ㆍArytenoid cartilage.

Formation of a Tracheoesophageal Common Channel After Alkaline Injury

We describe tracheoesophageal common channel formation in a 40-year-old woman who swallowed alkaline detergent. Necrosis and fistula formation between the posterior tracheal wall and the anterior esophageal wall were visualized by panendoscopy 15 days after the injury. Urgent tracheostomy, tube hypopharyngostomy, gastrostomy, and feeding jejunostomy were performed. Tracheoesophageal common channel formed by anterior tracheal wall and posterior esophageal wall was visualized by bronchoscopy at 48 days after the injury. Progression was observed by a panendoscopy, bronchoscopy, and chest computed tomography. Sequelae included trismus, obliteration of laryngopharynx, proximal cervical esophagus, and thoracic esophagus below the carina, stomach stricture, and scarring of the scalp, neck, back, and thighs.

A Review of Urgent, Awake Tracheotomy: a Five-Year Experience at a Tertiary Referral/Level 1 Trauma Center in Portland, Oregon

Statement of the Problem: There are many circumstances where we find ourselves in a situation where a secure airway is needed urgently. Our experience with urgent tracheotomies has helped us to develop a simple method of managing this difficult circumstance. In this case series, a sampling of our experience as the head and neck service at a tertiary referral center is examined and two cases are selected to demonstrate clinical scenarios where urgent tracheotomy was necessary. Additionally, our technique is presented so as to illustrate how to quickly and efficiently perform this procedure.

Laryngospasm as preceding symptom of amyotrophic lateral sclerosis

A 62-year-old man presented with paroxysmal sensation of suffocation, each time lasting for about 10 s. They were not triggered by body position, physical exercise, or sleep, and there was no associated dysphagia, dysphonia, cough, stridor, or pyrosis. Clinical examination was normal. A diagnosis of laryngospasm was evoked. Electromyography (EMG), including bulbar exploration, brain and cervical spine MRI, direct laryngoscopy (performed in absence of clinical symptoms), and esophagogastroscopy were normal. Laryngospasms persisted after gastric antisecretory medication. CAG repeat length in the androgen receptor gene, in search for Kennedy’s disease, was normal. One year after laryngospasm onset, progressive distal left arm weakness occurred. Clinical examination revealed left thenar, hypothenar, and interossei muscle weakness and atrophy, fasciculations in both upper limbs and tongue, generalized deep tendon hyperreflexia, left-sided Babinski sign, hypernasal voice, brisk jaw-jerk, and emotional lability. EMG showed reduced compound motor action potential amplitude in the left arm without conduction block on nerve conduction studies, with normal F-wave and sensory nerve conduction studies. Electromyographical exploration showed diffuse fibrillations and positive sharp waves at rest in the left upper limb, both lower limbs, and paravertebral muscles, together with large, long and polyphasic muscle unit potentials during muscle contraction. EMG of bulbar muscles was normal. Positron emission tomography with fludeoxyglucose F 18 showed a severe hypometabolism of bilateral temporal and frontal lobes and anterior cingular region. A diagnosis of amyotrophic lateral sclerosis (ALS) was made in presence of El Escorial criteria. Functional pulmonary exploration was normal. Frequency of laryngospasm remained stable the first year following ALS diagnosis. Laryngospasm is clinically defined as a sudden-onset sensation that air cannot be moved in or out, usually followed by inspiratory stridor, due to a rapid and forceful contraction of the laryngeal sphincter [1]. It sometimes results in loss of consciousness making urgent tracheostomy necessary [2]. A gastroesophageal reflux disease is found in 80% of patients with laryngospasm [3]. ALS is defined by progressive degeneration of upper and lower motor neurons. One-third of ALS patients present with bulbar symptoms [4]. In a large cohort of 44 ALS patients with initial bulbar symptoms, none had isolated laryngospasm [5]. Laryngospasm is reported in 2% of ALS patients in early clinical stage, but seems to be more frequent in later stages of the disease [6, 7]. Kennedy’s disease (KD) is characterized by lower motor neuron dysfunction with predominant bulbar involvement. Laryngospasms have been described in 47% in a series of 49 KD patients [6]. All of these patients had bulbar involvement and 65% had pyrosis. Laryngospasm was observed in all stages of KD and there was no increase in frequency of laryngospasm in later stages of the disease. In two-thirds of the patients with laryngospasm and associated pyrosis, laryngospasm was reduced by gastric antisecretory and prokinetic drugs. Our presented patient is the first case of laryngospasm preceding ALS diagnosis. Laryngospasm was probably related to ALS since there were no arguments for G. Fourcade (&) G. Castelnovo D. Renard P. Labauge Department of Neurology, CHU Nimes, Service des Explorations Fonctionnelles du Systeme Nerveux, Hopital Caremeau Place du Pr Debre, 30029 Nimes Cedex 9, France e-mail: n.fourcade@wanadoo.fr

Stridor as initial clinical presentation of tracheal chondroma

Chondromas are benign cartilaginous tumours that are uncommon in the head and neck region. Only few cases of chondroma have been reported in the trachea. We present a 70-year-old patient who presented clinically with severe dyspnoea requiring urgent tracheotomy. An oval, expansive, well-delineated tracheal tumour was evident on magnetic resonance imaging. The mass was removed surgically in its entirety, preserving tracheal rings, and the histopathological diagnosis was chondroma. The patient was decannulated after 2 months, and was followed for 3 years. Urgent tracheotomy is an unusual initial clinical manifestation of this infrequent tumour. Surgical options and the choice of therapy in this case are discussed.

The tracheotomy punch for urgent tracheotomy

Tracheotomy is a commonly performed surgical technique used for long-term mechanical ventilation, upper airway obstruction, need for pulmonary toilet, and as an adjunct to surgery where ventilation is anticipated. Urgent tracheotomy may be performed when difficulty is encountered during an elective tracheotomy, or when cricothyroidotomy is impossible or contraindicated due to distorted anatomy or laryngeal obstruction. Various methods of creating a tracheal opening have been described and each of these methods has technical advantages and disadvantages. In the urgent setting, a rapid and technically simple approach is needed for optimal results. We have used the Eisele tracheotomy punch (Pilling, Teleflex Medical, Research Triangle Park, NC) for all tracheotomies, both elective and urgent. In this report we describe five illustrative cases in which the tracheotomy punch was used successfully in the urgent setting to ensure rapid airway access.

The Tracheotomy Punch for Urgent Tracheotomy

Tracheotomy is a commonly performed surgical technique used for long-term mechanical ventilation, upper airway obstruction, need for pulmonary toilet, and as an adjunct to surgery where ventilation is anticipated. Urgent tracheotomy may be performed when difficulty is encountered during an elective tracheotomy, or when cricothyroidotomy is impossible or contraindicated due to distorted anatomy or laryngeal obstruction. Various methods of creating a tracheal opening have been described and each of these methods has technical advantages and disadvantages. In the urgent setting, a rapid and technically simple approach is needed for optimal results. We have used the Eisele tracheotomy punch (Pilling, Teleflex Medical, Research Triangle Park, NC) for all tracheotomies, both elective and urgent. In this report we describe five illustrative cases in which the tracheotomy punch was used successfully in the urgent setting to ensure rapid airway access.

Diagnosis and treatment of an infant case with temporomandibular joint osteoarthritis caused by tumor

We reported an infant with temporomandibular joint (TMJ) osteoarthritis who required long-term tracheostomy. At 1 year of age, he received urgent tracheostomy because of apnea due to pneumonia. The tracheal cannula could not be removed thereafter due to trismus. Computed tomography (CT) images demonstrate irregular bone formation. However, we could not diagnose osteoarthritis of temporomandibular joint because TMJ adhesion was not clear on CT images. Arthroplasty was performed under general anesthesia, but there was no significant improvement. A 3-D plastic model based on intraoperative findings showed that atrophic change of the muscles also disturbed movement of the mandible. Therefore, an additional procedure called "pan-muscle-release surgery" was performed, resulting in further improvement of mandible movement. After confirming that mouth opening was stable, the tracheal cannula was removed.

Incidence of perioperative airway complications in patients with previous medialization thyroplasty

Determine the incidence and characterize perioperative airway complications in patients who have undergone medialization thyroplasty (MT) and subsequently undergo procedures requiring anesthesia. Retrospective review of post-MT anesthesia encounters in a large academic hospital. A series of post-MT patients was reviewed, identifying anesthesia encounters undergoing endotracheal intubation (ETI) or laryngeal mask airway (LMA) placement. Details on the perioperative course of each encounter were extracted and examined for evidence of airway complications. The incidence of airway obstruction and need for airway intervention were determined and compared to those of control patients matched for type of procedure. Relationships between complications and perioperative management were analyzed. A total of 74 anesthesia encounters were identified among 219 post-MT patients. Perioperative airway complications among post-MT patients arose in five procedures (6.8%; 95% CI: 1.0-12.4%). Stridor in the operating or recovery room was exhibited three times, with all episodes requiring nebulized racemic epinephrine and intravenous steroids for resolution of symptoms. One patient underwent an urgent tracheotomy for severe stridor leading to airway compromise in the recovery room. Immediately after induction with an LMA, one patient failed to maintain oxygen saturations above 90% and consequently required conversion to ETI. Among 79 matched controls without prior MT, no perioperative complications (0%) occurred (P = .027). The incidence of perioperative airway complications in post-MT patients is non-neglible and may be serious. Surgical, anesthesia, and recovery room staff should be made aware of the significantly increased risk of airway complications in post-MT patients.

Tracheopathia chondro-osteoplastica – an unusual cause of stridor

A case of tracheopathia chondro-osteoplastica causing sub-glottic stenosis is described. Case report and literature review. A 37-year-old man presented with a 15-year history of gradually worsening dyspnoea and stridor due to sub-glottic stenosis. His medical and radiographic records were reviewed. This patient's presentation, histopathological findings and radiology images are presented and discussed. Histopathological evaluation of microlaryngoscopy biopsy specimens, taken during laser debulking of the stenosis, confirmed the presence of tracheopathia chondro-osteoplastica. This is the first reported case of sub-glottic stenosis caused by tracheopathia chondro-osteoplastica which required an urgent tracheostomy.

Clinical features and therapeutic management of subglottic stenosis in patients with Wegener’s granulomatosis

The objective of the study was to evaluate the clinical features, response to treatment, and long-term outcome of subglottic stenosis (SGS) in a series of patients diagnosed as having Wegener's granulomatosis (WG) at a single institution. Subglottic stenosis developed in 6 out of 51 (11.7%) patients, in four of them in the absence of other features of active disease, and was the symptom that leads to WG diagnosis in three cases. In two cases, SGS began while the patients were receiving systemic immunosuppressive therapy for disease activity involving other sites. PR3-ANCAs were positive in four cases. An urgent tracheostomy was needed in two patients. Four patients achieved SGS clinical remission on standard treatment with glucocorticoids and cyclophosphamide, but three of them experienced repeated local relapses and required additional immunosuppressive therapy and mechanical dilations. In one case, a local relapse was successfully managed with endotracheal dilation of the stenotic segment and intralesional injection of a long-acting corticosteroid plus mechanical dilation of the stenotic segment (ILCD) without adding supplemental immunosuppressant drugs. Two patients with isolated SGS were also successfully managed with ILCD alone and did not require the institution of systemic immunosuppressive therapy. One patient underwent open surgical repair when the disease was under control. Our data suggest that Subglottic stenosis often occurs or progresses independently of other features of active WG, and that ILCD may be a safe alternative to conventional immunosuppressive therapy in patients who develop SGS in the absence of other features of active disease, allowing reducing the treatment-related toxicity.

Submental Intubation Versus Tracheostomy in Maxillofacial Trauma Patients

To evaluate the indications and outcomes of airway management by submental intubation or tracheostomy in patients with maxillofacial trauma, and to describe the technique of submental intubation in detail and discuss its latest refinements. Of 356 patients admitted from January 2004 through September 2007 with maxillofacial trauma, 222 were operated on under general anesthesia. Eight patients underwent urgent or elective tracheostomy; 8 patients underwent submental intubation. Seven patients with submental intubation were extubated at the end of the procedure. One patient received elective tracheostomy 3 days later. We did not encounter any complications in the tracheostomy group, while 1 case of slight damage to the endotracheal tube occurred in the submental intubation group. Submental endotracheal intubation is a simple technique with very low morbidity and can replace tracheostomy in selected cases of maxillofacial trauma without indication for prolonged ventilation support.