Delayed onset postoperative retropharyngeal hematoma after anterior cervical surgery with a sequela of tracheal stricture: a case report

Background Among the several complications associated with anterior cervical discectomy and fusion (ACDF), airway compromise is considered one of the serious life-threatening conditions and usually requires emergent treatment, including airway establishment and hematoma evacuation surgery. Postoperative retropharyngeal hematoma commonly occurred during the on immediate phase with airway compromise, but have a rarity on late onset of this complication. Enlightened by this existing fact, we report the first case of delayed onset postoperative retropharyngeal hematoma after anterior cervical surgery with a sequela of tracheal stricture. Case presentation A 55-year-old male underwent ACDF for disc herniation at C5–6 that had not responded to conservative treatment over 3 months. The symptoms significantly improved after surgery, and he was discharged on postoperative day 3. On the 7 days after ACDF, the patient complained of sudden-onset left-deviated neck swelling. The follow-up plain radiographs and neck-enhanced computed tomography (CT) scans showed anterior and right lateral displacement of the airway including the trachea by a large retropharyngeal hematoma. We performed an emergent forceful endotracheal intubation that was maintained for 2 days until the patient underwent hematoma evacuation surgery. On the second day after hematoma evacuation surgery, the patient complained of hoarseness with a foul breath odor. Laryngoscopy showed tracheal ischemic mucosal damage that had been induced by forceful endotracheal intubation. Antibiotics and systemic corticosteroids were administered, and the symptoms improved. One month after hematoma evacuation surgery, he complained of dyspnea on exertion, and laryngoscopy showed tracheal stricture. The patient underwent bronchoscopic dilatation and is doing well without recurrence of symptoms. Conclusions Early surgery to remove the delayed onset retropharyngeal hematoma, rather than forceful endotracheal intubation followed by delayed surgery, might yield better results and avoid unexpected complications of tracheal stricture.

Delayed Onset Postoperative Retropharyngeal Hematoma After Anterior Cervical Surgery With a Sequela of Tracheal Stricture: a Case Report

Background: Among the several complications associated with anterior cervical discectomy and fusion (ACDF), airway compromise is considered one of the serious life-threatening conditions and usually requires emergent treatment, including airway establishment and hematoma evacuation surgery. Postoperative retropharyngeal hematoma commonly occurred during the on immediate phase with airway compromise but have a rarity on late onset of this complication. Enlightened by this existing fact, we report the first case of delayed onset postoperative retropharyngeal hematoma after anterior cervical surgery with a sequela of tracheal stricture. Case presentation: A 55-year-old male underwent ACDF for disc herniation at C5-6 that had not responded to conservative treatment over three months. The symptoms significantly improved after surgery, and he was discharged on postoperative day 3. On the seven days after ACDF, the patient complained of sudden onset left-deviated neck swelling. The follow-up plain radiographs and neck-enhanced computed tomography (CT) scans showed anterior and right lateral displacement of the airway including the trachea by a large retropharyngeal hematoma. We performed an emergent forceful endotracheal intubation that was maintained for two days until the patient underwent hematoma evacuation surgery. On the second day after hematoma evacuation surgery, the patient complained of hoarseness with a foul breath odor. Laryngoscopy showed tracheal ischemic mucosal damage that had been induced by forceful endotracheal intubation. Antibiotics and systemic corticosteroids were administered, and the symptoms improved. One month after hematoma evacuation surgery, he complained of dyspnea on exertion, and laryngoscopy showed tracheal stricture. The patient underwent bronchoscopic dilatation and is doing well without recurrence of symptoms. Conclusions: Early surgery to remove the delayed onset retropharyngeal hematoma, rather than forceful endotracheal intubation followed by delayed surgery, might yield better results and avoid unexpected complications of tracheal stricture.

Role of air way stenting (Duman- silica stent) in benign stricture trachea management

Background: Tracheal strictures are known to recur after dilatation, so they need stenting to prevent recurrence. The objective was to study role of air way stenting (Duman- silica stent) in benign stricture trachea management.Methods: A hospital based prospective study was carried out among 15 cases (as these cases are very rare, author could study only 15 cases) presented with various clinical features suggestive of tracheal strictures. They were examined and managed by putting tracheal stent for up to eight months period. All cases were followed at regular intervals till 14months after the stent was placed. The outcome was studied.Results: The tracheal strictures have been found to be more in the age group of 25-30 years. The male to female ratio was 4:1 i.e. for everyone female case there were four male cases. Thus, the tracheal strictures have been more common among the males compared to the females. All of the patients presented with severe stridor, breathing difficulty, and poor exercise tolerance. Most common cause of tracheal stricture was prolonged mechanical ventilatory support >8 days due to organo phosphorus poisoning in past 3months and all of them were males. All cases had good outcome at the end of 14months of follow up. All cases had normal findings. No one developed foreign body reaction, nor did no one develop granuloma formation at the stent site. After stent removal flexible bronchoscopy repeated after 3rd month and 6th month.Conclusions: Tracheal stenting is very useful procedure in the management of air way strictures.

Tracheo-oesophageal fistula in a patient with chronic sarcoidosis

Sarcoidosis is a common multisystem granulomatous condition of unknown aetiology, predominantly involving the respiratory system. Tracheal stenosis has been described but we believe that we present the first case of a tracheo-oesophageal fistula secondary to chronic sarcoidosis. A 57-year-old woman with sarcoidosis, a known tracheal stricture and a Polyflex® stent in situ presented with stridor. Bronchoscopy confirmed in-stent stenosis, by exuberant granulation tissue. The stent was removed and the granulation tissue was resected accordingly. Postoperatively, the patient was noticed to have an incessant cough and video fluoroscopy raised the suspicion of a tracheo-oesophageal fistula. A repeat bronchoscopy demonstrated marked granulation tissue, accompanied by a fistulous connection with the oesophagus at the mid-lower [middle of the lower] third of the trachea. Three Polyflex® stents were sited across the entire length of the trachea. Sarcoidosis presents with varying clinical manifestations and disease progression. Tracheal involvement appears to be a rare phenomenon and usually results in stenosis. To date, there has been little or no documented literature describing the formation of a tracheo-oesophageal fistula resulting from sarcoidosis. Early reports documented the presence of sarcoidosis induced weakening in the tracheal wall, a process termed tracheal dystonia. Weaknesses are more apparent in the membranous aspect of the trachea. Despite the rare nature of such pathology, this case report highlights the need to consider the presence of a tracheo-oesophageal fistula in sarcoidosis patients presenting with repeat aspiration in the absence of an alternate pathology.