Ventilation failure with elective tracheostomy during oral cancer surgery: a case of tracheal diverticulum

Abstract

Tracheal diverticulum is usually detected incidentally. Rarely, it may lead to difficulty in securing the airway intraoperatively. Our patient underwent oncological resection under general anaesthesia for advanced oral cancer. Elective tracheostomy was performed at the end of the surgery, and a cuffed tracheostomy tube (T-tube) of 7.5 mm size was inserted through the tracheostoma. Despite repeated attempts at T-tube insertion, ventilation could not be established. However, on advancing the endotracheal tube beyond tracheostoma, ventilation was restored. The T-tube was inserted into the trachea under fibreoptic guidance achieving successful ventilation. A fibreoptic bronchoscopy through the tracheostoma performed after decannulation revealed a mucosalised diverticulum extending behind the posterior wall of the trachea. The bottom of the diverticulum showed mucosa-lined cartilaginous ridge with differentiation into smaller bronchiole-like structures. Tracheal diverticulum should be considered as a possible differential in case of failed ventilation following an otherwise uneventful tracheostomy.

Keywords: Cancer intervention; Ear, nose and throat/otolaryngology; Head and neck cancer; Head and neck surgery.

Figure 1

Endoscopic view via the tracheostoma immediately below the tracheostoma. Black arrow—opening of the tracheal diverticulum into trachea; white arrow—tracheal lumen; *—partition between the tracheal lumen and diverticulum.

Figure 2

Contrast-enhanced CT: (A) axial, (B) sagittal and (C) coronal views showing the tracheal diverticulum. The intersection of vertical and horizontal cross-reference lines is centred over the lower part of the diverticulum. The red arrow is pointing towards the Ryle’s tube in oesophagus in (A), towards the tracheostoma in (B) (note the relationship between the tracheostoma and upper part of diverticulum) and towards carina in (C). Measuring tool in (A) shows the diameter of the diverticulum to be around 5.7 mm (yellow oblique line); while in (B), the length of diverticulum can be seen to be around 28 mm (vertical green line).

Figure 3

Sagittal view of the neck and upper chest showing the trajectory of tracheostomy (red tube) and endotracheal tube (green tube) during cannulation into the trachea. The tracheostomy tube with obturator has a tendency to slide into the opening of the diverticulum (red arrow is pointing towards the proximal part of the diverticulum) during cannulation, while the distal part of the endotracheal tube enters nearly tangentially to the tracheal lumen avoiding the entry into the diverticulum. A, anterior; P, posterior.