Airway management of a patient with laryngotracheal disruption following blunt neck trauma

Dear Editor, A 28-year-old male patient presented with history of trauma neck while riding bike, after being entangled by an electric wire around his neck. On arrival, the patient was stable with 96% saturation and had minimal contusion in front of neck and subcutaneous emphysema. Computed tomography neck showed discontinuity of larynx and trachea [Figure 1: CT showing laryngo-tracheal disruption].Figure 1: CT showing laryngo-tracheal disruptionThe patient soon became severely dyspnoeic and restless along with stridor and inability to lie down. Subcutaneous emphysema had worsened with extension to face and chest. Saturation dropped to 90% and emergency tracheostomy was decided. The patient was in severe distress and unable to lie down. The plan was to do awake fiber-optic-assisted intubation as trachea was nonpalpable due to increasing subcutaneous emphysema for tracheostomy to be performed under local anesthesia. In the operating room, the patient was made to sit on the table. Electrocardiogram, pulse oximetry, and noninvasive blood pressure monitors were attached. Upper airway was topicalized with 10% lignocaine spray and 2% lignocaine jelly. Fiber-optic bronchoscope (FOB) preloaded with 7.0 size endotracheal tube was passed nasally while the patient was in sitting position with the anesthetist facing the patient. As epiglottis was visualized, 4 mL of 4% lignocaine was sprayed through the side port of FOB. In the first attempt, scope was passed beyond the vocal cords but trachea could not be visualised and scope entered a blind sac. During the second attempt, tracheal rings were visualized. Trachea was found to be grossly deviated to one side and was not in alignment with glottis. FOB was advanced into trachea till carina and endotracheal tube was railroaded over it. Successful intubation was confirmed with end-tidal carbon dioxide and auscultation. Following induction and neuromuscular blockade, the patient was ventilated with oxygen in air with isoflurane. During tracheostomy, it was noticed that cricothyroid ligament was maintaining a structural continuity between larynx and a displaced trachea which acted as a conduit before intubation. Following tracheostomy, the patient was stable and had an unremarkable recovery. Definitive surgical correction was done 1 month later. Blunt neck trauma is uncommon but potentially life-threatening injury in the form of loss of airway.[12] Early recognition of nature of injury is vital and presence of contusion and stridor indicates severe injury.[3] Tailoring the technique of securing airway to each case is important.[4] Inability to cooperate for topicalization and bleeding may obscure vision during FOB in these patients. If tracheostomy is planned under local anesthesia, FOB-guided airway examination may help assess the extent of airway trauma. In our patient, an attempt to intubate with direct or video laryngoscope could have led to instrumentation of the blind pouch which was in line with larynx. Due to the presence of surgical emphysema, ultrasound had minimal role in identifying trachea. If awake FOB had failed, the only backup plan was tracheostomy which would have been technically difficult due to surgical emphysema. We conclude that in case of blunt neck trauma, gross anatomical distortion should be anticipated. If endotracheal intubation is planned to secure the airway, awake FOB should be preferred over direct/video laryngoscopy if feasible. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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