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LETTERS TO EDITOR
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 162-163
 

Surgical emphysema leading to respiratory distress following partial cricotracheal resection for subglottic stenosis in a paediatric patient


1 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Command Hospital (Southern Command), Pune, Maharashtra, India
2 Department of ENT, Armed Forces Medical College, Command Hospital (Southern Command), Pune, Maharashtra, India

Date of Submission23-Feb-2020
Date of Acceptance25-Mar-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Dr. Deepak Dwivedi
Department of Anaesthesia and Critical Care, Armed Forces Medical College, Command Hospital (Southern Command), Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_15_20

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How to cite this article:
Dwivedi D, Gupta V, Dwivedi G, Singh S. Surgical emphysema leading to respiratory distress following partial cricotracheal resection for subglottic stenosis in a paediatric patient. Indian Anaesth Forum 2020;21:162-3

How to cite this URL:
Dwivedi D, Gupta V, Dwivedi G, Singh S. Surgical emphysema leading to respiratory distress following partial cricotracheal resection for subglottic stenosis in a paediatric patient. Indian Anaesth Forum [serial online] 2020 [cited 2020 Oct 30];21:162-3. Available from: http://www.theiaforum.org/text.asp?2020/21/2/162/295322




Sir,

Acquired subglottic stenosis (SGS) with the incidence between 1% and 8% follows the consequences of prolonged intubation. Other risk factors include gastro-oesophageal reflux, repeated intubations, low birth weight (<1500 g).[1] The SGS is graded according to the Cotton Meyer Classification. The treatment options offered for higher Grades (III and IV) are amenable to partial cricotracheal resection (PCTR) or laryngotracheal resection with posterior cricoid split with grafting.[1],[2] We present a life-threatening airway emergency following PCTR surgery in a paediatric patient.

A 5-year-old male child weighing 14 kg, an operated case of ventricular septal defect, transposition of the great arteries with acquired sub glottic stenosis (Grade IV) following prolonged intubation, with tracheostomy tube in situ presented to this hospital. Child was evaluated by head and neck onco-surgeons and non-contrast-enhanced computed tomography neck confirmed the narrowing from the level of arytenoids and caudally for a length of 7 mm. Child underwent single stage PCTR with primary thyrotracheal anastomosis under general anaesthesia. He was shifted to paediatric intensive care unit (PICU) on mechanical ventilation (pressure control mode) with sedation protocol of PICU. Patient was extubated on seventh postoperative day (POD) once fibreoptic laryngoscopy (FOL) (size 2.4 mm pentax) confirmed the integrity of anastomosis.

On 16th POD the child had a brief bout of cough, following which he developed difficulty in breathing with desaturation (SpO2 between 82% and 84% with oxygen supplementation). Examination revealed. Surgical emphysema at the incision site in the neck between the sternocleidomastoids laterally, hyoid superiorly and suprasternal notch inferiorly.

In wake of dehiscence of the anastomotic line, the patient was shifted to operation theatre (OT) and was orally intubated. The tracheostomy trolley with ear, nose and throat surgeons was standby. Child was ventilated with increased ventilatory rate and tidal volume of 4–5 ml/kg to prevent the loss of tidal volume in the subcutaneous tissue as there was an evident pericuff leak as cuff volume could not be increased to prevent damage to the healing posterior wall of the anastomosis [Figure 1].
Figure 1: The surgical emphysema at the incision site in the neck

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Re-exploration revealed anastomotic leak of 1 cm × 1 cm in the anterior tracheal wall, which was re-anastomosed with intact posterior tracheal wall. Child was shifted to PICU on ventilator. On eighth POD a check FOL revealed a well healing anastomosis with minimal mucosal oedema. Successful extubation was done and oxygen supplementation with adrenaline nebulization (1:1000 3–5 ml) was followed by steroid nebulization.

Complications following PCTR can be classified as anastomotic or nonanastomotic. Anastomotic complications as quoted by Bibas et al. include, re-stenosis in 16% patients and about 4.6% patients developed anastomotic dehiscence requiring re-exploration.[3] Yamamoto et al. did analysis of the data base on their 129 paediatric patients following PCTR and found anastomotic dehiscence in 10% of the patients.[4] Development of well localized surgical emphysema consequent to anastomotic dehiscence following PCTR surgery perhaps, was due to walling off by the healing neck tissues. In our case the ventilatory failure resulted as the proportion of the child's tidal volume was lost through the dehiscence site into subcutaneous tissue. Therefore, vigilant monitoring and timely intervention resulted in an effective airway management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eid EA. Anesthesia for subglottic stenosis in pediatrics. Saudi J Anaesth 2009;3:77-82.  Back to cited text no. 1
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2.
George M, Jaquet Y, Ikonomidis C, Monnier P. Management of severe pediatric subglottic stenosis with glottic involvement. J Thorac Cardiovasc Surg 2010; 139:411-7.  Back to cited text no. 2
    
3.
Bibas BJ, Terra RM, Oliveira Junior AL, Tamagno MF, Minamoto H, Cardoso PF, et al. Predictors for postoperative complications after tracheal resection. Ann Thorac Surg 2014;98:277-82.  Back to cited text no. 3
    
4.
Yamamoto K, Jaquet Y, Ikonomidis C, Monnier P. Partial cricotracheal resection for paediatric subglottic stenosis: Update of the Lausanne experience with 129 cases. Eur J Cardiothorac Surg 2015;47:876-82.  Back to cited text no. 4
    


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