Abstract
Endoscopic balloon dilation of tracheal stenosis is usually a safe procedure. However, there are life-threatening complications that physicians performing the procedure need to be aware of. A 43-year old woman with a multi-level tracheal stenosis following lengthy intubation and a tracheostomy was treated with endoscopic balloon dilation. This resulted in an almost total rupture of the posterior tracheal wall. Here a safe and successful conservative treatment approach is reported.
Introduction
Endoscopic balloon dilation of tracheal stenosis is a procedure with relatively low morbidity. [Citation1] However, there are potentially life-threatening complications such as balloon air entrapment and lacerations of the posterior membranous wall. These lacerations can be classified using a system proposed by Cardillo et al. (Table ) [Citation2]. Few cases of tracheal rupture following endoscopic dilation have been reported [Citation3,Citation4]. Some have been treated with surgical repair [Citation3]. In one case a level IIIA laceration was successfully treated with a tracheal stent [Citation4]. Here a successful conservative treatment approach is reported.
Table 1. Classification of tracheal lacerations proposed by Cardillo et al. [Citation2].
Case
A 43-year-old woman had twenty years earlier undergone prolonged intubation and a tracheostomy following a traffic accident in her country of origin. Five years later she had immigrated to this country and presented with dyspnea during exercise and upper airway infections.
Synechiae of the posterior glottis were revealed and treated with a CO2 laser. In addition, an A-frame tracheal stenosis at the location of the tracheostomy was left untreated since her breathing improved following surgery.
Fifteen years later, she presented with increased dyspnea on exertion. Spirometry showed mild to moderate upper airway obstruction. Laryngoscopy revealed a relatively good vocal fold movement and the patient was opted for an endoscopic balloon dilation of the tracheal stenosis. Under suspension laryngoscopy in general anesthesia, using Superimposed High-Frequency Jet Ventilation (Twinstream™) (Carl Reiner GmbH, Vienna, Austria) a 10-cm long Rigiflex II esophageal dilation balloon (Boston Scientific, Marlborough, MA, USA) with a 3 cm diameter, in absence of continuous radial expansion balloons, was advanced into the stenotic part of the trachea and inflated to 1 atm pressure. Inspection revealed a total rupture of the posterior tracheal wall from the cricoid to the carina (Figure ). Esophagoscopy showed no penetrating injury and a CT scan showed no signs of pneumo-mediastinum (Figure ). The laceration was classified as level IIIA (Table ). A cardiothoracic surgeon was consulted and after examining different treatment options including surgical repair and endotracheal stenting, a conservative treatment strategy was decided on.
Figure 1. Endoscopic view of a level IIA-tracheal rupture following balloon dilatation of a tracheal stenosis.
Figure 2. Computed tomography scans two hours after tracheal rupture with no signs of pneumo-mediastinum (A) and six days later showing complete closure (B).
Since intubation was considered unsafe the patient was transferred to the ICU ventilated with a Laryngeal Mask Airway (LMA). Muscle relaxation (pancuronium) was used to prevent coughing. Cefuroxim (1.5 g three times daily) was administered for prophylaxis. The patient remained afebrile, the C-reactive protein peaked at 50 mg/L and the leukocyte count was mildly increased. On the third post-operative day, the patient’s condition remained stable and following lidocaine infusion (1 mg/ml) to prevent coughing, the LMA was removed and she was transferred to the ward. Ethylmorphinehydrochloride (25 mg four times daily) was prescribed to minimize coughing. Six days postoperatively a new CT scan showed complete closure of the laceration (Figure ). She was discharged after an eight-day admission and remained asymptomatic as she was followed uneventfully for more than ten years.
Discussion
Tracheal rupture following endoscopic dilation of subglottic stenosis is a rare, potentially life-threatening complication. Physicians performing the procedure should be aware of and have a strategy for it. Here we have reported a conservative treatment approach of a Level IIIA tracheal laceration. Successful conservative treatment of tracheal ruptures have been reported previously in both children and adults [Citation4,Citation5]. A very similar case was treated effectively with a tracheal stent [Citation4]. However, a tracheobronchial stent is not risk-free; life-threatening stent migration and mucus plugs could occur [Citation6]. Also, because the closure of the similar laceration in our case was achieved within a week there was in our opinion, no need for a stent. The LMA approach used in this case is, to our knowledge, not reported before. There was a concern that this could increase the airway pressure and therefore the tracheal damage. To prevent this muscle relaxation was used until the LMA was removed. In this case, the approach was both safe and successful and the patient did not need an airway stent and the risks associated with it. It is always better to prevent than manage complications. Balloon dilation distal to the supporting cricoid cartilage could increase the risk of posterior wall rupture and extra care should be taken to avoid this. When dedicated airway dilation balloons now are widely available non-airway balloons (for instance the esophageal balloon used in this case) should not be used. The authors encourage other colleagues to consider the conservative approach reported here in cases with tracheal rupture without signs of esophageal injury and/or mediastinitis.
Conclusion
A level IIIA tracheal rupture following endoscopic balloon dilation could be safely and successfully treated conservatively in this case.
Informed consent
Informed consent for the publication of clinical information and images was obtained from the patient.
Disclosure statement
The authors have no funding, financial relationships, or conflicts of interest to disclose.
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