Airway Management of Asymptomatic Tracheal Stenosis in Adult: A Case Report

Hemlata Kapoor¹ https://orcid.org/0000-0003-1821-603X, Rajashree Choudhury², Manish Jethani³

^1,2Department of Anesthesia, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute (KDAH), Mumbai, Maharashtra, India

³Department of Oncosurgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute (KDAH), Mumbai, Maharashtra, India

Corresponding Author: Hemlata Kapoor, Department of Anesthesia, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute (KDAH), Mumbai, Maharashtra, India, Phone: +91 9321313799, e-mail: h_sarinkapoor@hotmail.co.uk

Received: 04 April 2024; Accepted: 12 July 2024; Published on: 18 December 2024

ABSTRACT

Aim and background: Congenital tracheal stenosis is usually diagnosed during infancy because of respiratory distress. It presents as both inspiratory and expiratory stridor and is often associated with cardiopulmonary abnormalities. Undiagnosed tracheal stenosis without associated symptoms can lead to unanticipated difficult intubation and escalate to an airway emergency.

Case description: We present a case of a 47-year-old female who was being evaluated for a renal transplant. A computerized tomography scan of the chest reported significant luminal compromise of the trachea at the level of the thyroid gland, with a maximum dimension of 7–8 mm in the sagittal plane. In the operating theatre, after confirming adequate face mask ventilation, a muscle relaxant (atracurium) was given as per body weight. Laryngoscopy was done using a size 3.5 McCoy, and the view according to the modified Cormack–Lehane was grade 2a. A size 6.0 mm internal diameter (ID) endotracheal tube, which has an outer diameter (OD) of 8.2 mm, was placed comfortably in the trachea. A size 6.5 tube (ID 6.5 mm, OD 8.9 mm) was found to be snugly fitting. The airway pressures were within the normal range during volume control ventilation. At the end of surgery, the trachea was extubated, and the patient was comfortable.

Conclusion: There are no established airway management guidelines for such patients. In patients already diagnosed with tracheal stenosis, careful assessment and planning for intubation are essential for the smooth conduct of anesthesia.

Clinical significance: A detailed history and careful inspection of available thoracic imaging can help in foreseeing unanticipated difficult intubations like tracheal stenosis.

Keywords: Anesthesia, Case report, Endotracheal tube, Tracheal stenosis

How to cite this article: Kapoor H, Choudhury R, Jethani M. Airway Management of Asymptomatic Tracheal Stenosis in Adult: A Case Report. Res and Innov Anesth 2024;9(2):61–63.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

INTRODUCTION

Congenital tracheal stenosis is usually diagnosed during infancy because of respiratory distress. It presents as both inspiratory and expiratory stridor and is often associated with cardiopulmonary abnormalities.¹ Undiagnosed tracheal stenosis without associated symptoms can lead to unanticipated difficult intubation and escalate to an airway emergency.

Cantrell and Guild described three kinds of tracheal stenosis: generalized hypoplasia, funnel-like stenosis, and segmental stenosis.² Other conditions presenting as stridor are tracheomalacia, foreign body, and external compression of the trachea due to a mediastinal mass or a congenital vascular ring.³

CASE DESCRIPTION

We present a case of a 47-year-old female who was being evaluated for a renal transplant. A computerized tomography scan of the chest reported significant luminal compromise of the trachea at the level of the thyroid gland, with a maximum dimension of 7–8 mm in the sagittal plane (Fig. 1). However, no external compression was detected. Tracheal collapse during respiration was not visualized while performing imaging. Chronic thrombosis of the distal right internal jugular vein and right subclavian vein, extending into the innominate vein for an approximate length of 5.4 cm, was reported. The left innominate vein and superior vena cava were reported to be normal. Multiple collaterals were present on the anterior chest wall. This thrombosis was noted following internal jugular vein cannulation for the insertion of a hemodialysis catheter. The pulmonary function test was normal and excluded any significant obstructive or restrictive defects. A flexible laryngoscopy was requested, which showed a narrow tracheal segment near the cricoid ring (Fig. 2). However, the patient never exhibited signs or symptoms of tracheal obstruction.

Fig. 1: Computed tomography scan showing narrowing of trachea

Fig. 2: Bronchoscopy showing narrowing of tracheal lumen

On the day of surgery, after attaching routine monitors, induction of anesthesia was started. After confirming adequate face mask ventilation, a muscle relaxant (atracurium) was given according to body weight. Laryngoscopy was performed using a fiberoptic laryngoscope with a flexitip blade size 3.5 (Green® Spec Pro), and the view according to the modified Cormack–Lehane was grade 2a. As discussed with the laryngologist, a size 6.0 mm internal diameter (ID) endotracheal tube, which has an outer diameter (OD) of 8.2 mm, was placed comfortably in the trachea. A size 6.5 tube (ID 6.5 mm, OD 8.9 mm) was found to be snugly fitting. The cuff of the 6.0 mm endotracheal tube was inflated to a pressure of 20 cmH₂O. The airway pressures were within the normal range during volume control ventilation. At the end of surgery, the trachea was extubated, and the patient was comfortable. A pediatric bronchoscope was kept ready during intubation and extubation as a standby.

DISCUSSION

Cantrell and Guild described three kinds of tracheal stenosis—generalized hypoplasia, funnel-like stenosis, and segmental stenosis.² Other conditions presenting as stridor include tracheomalacia, foreign body, and external compression of the trachea due to a mediastinal mass or a congenital vascular ring.³ Three-dimensional tracheal reconstructive images from computed tomography (CT) scan and virtual bronchoscopy, whenever available, can help in estimating the endotracheal tube size. The use of smaller-sized tubes, placement above the narrow segment, laryngeal mask airway, intubation with a fiberoptic bronchoscope, and in extreme emergencies, tracheostomy have been described.⁴^,⁸ Unanticipated difficult intubation often leads to multiple attempts, which can cause mucosal edema and even bleeding, worsening the already narrowed airway. Some of these patients have reported asthma-like features.⁸

CONCLUSION

There are no established airway management guidelines for such patients. In patients already diagnosed with tracheal stenosis, careful assessment and planning for intubation are essential for the smooth conduct of anesthesia. Accumulation of more case reports and studies, along with long-term follow-up of such patients, is required to understand this condition and its natural course.

Clinical Significance

A detailed history and careful inspection of available thoracic imaging can help in foreseeing unanticipated difficult intubations like tracheal stenosis.

ORCID

Hemlata Kapoor https://orcid.org/0000-0003-1821-603X

REFERENCES

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