CORRESPONDENCE

Late tracheostomy tube decannulation by progressionof a laryngeal tumour: an approach for airway control

Angela Truong, MD • Dam-Thuy Truong, MD

Received: 26 April 2011 / Accepted: 16 May 2011 / Published online: 27 May 2011

� Canadian Anesthesiologists’ Society 2011

To the Editor,

Malpositions of tracheostomy tubes constitute serious

complications. We describe a unique case of insidious

dislodgement of the tracheostomy tube from the trachea

due to aggressive growth of cancer. We highlight the

importance of recognizing this unusual late decannulation

and describe an approach for airway management. Written

patient consent was obtained for this report.

A 59-yr-old male with a T4 N2B laryngeal carcinoma

presented for laryngopharyngectomy and free flap recon-

struction. He had previously undergone a tracheostomy to

relieve airway obstruction. Despite treatment with che-

moradiation, the tumour progressed rapidly as evidenced

by a computed tomography scan seven months later which

showed cancer invading the thyroid, neck musculature, and

tracheostomy site. Furthermore, the tracheostomy tube was

seen pushed out of the tracheal lumen by progression of the

tumour (Figure, Panel A). On the day of surgery, the

patient was examined in the holding area. He was not in

respiratory distress; his O2 saturation was 97% on room air,

and a size 6.0 uncuffed Shiley� tube (Tyco Healthcare

Group LP, Pleasanton, CA, USA) located in the region of

his neck was encased by tumour. Based on physical

examination alone, there was no indication to arouse sus-

picion of decannulation.

A new tracheostomy could not be performed below the

existing dislodged tube due to tumour covering surface

anatomic landmarks of the patient’s neck. Similarly,

attempts at awake fibreoptic intubation (following airway

topicalization with nebulized lidocaine) were unsuccessful

because of diffuse carcinoma obstructing the glottic

opening.

The decision was made to use the existing tracheostomy

site to achieve endotracheal intubation. A flexible fibre-

optic bronchoscope was inserted into the Shiley� tube, and

the tip of the bronchoscope was confirmed to lie outside of

the tracheal lumen, partially obstructed by tumour (Figure,

Panel B). A path to the trachea was established by carefully

advancing the bronchoscope through the gap between the

distal end of the Shiley� and the tracheal lumen. The scope

was then removed and loaded with an Aintree� catheter

(Cook Incorporated, Bloomington, IN, USA). Bronchos-

copy was again performed to insert the Aintree� catheter

into the airway. Since the tissues around the catheter were

friable, a well-lubricated 6.0 reinforced endotracheal tube

was chosen for smooth sliding over the catheter as well as

for minimizing the possibility of dislodging tumour frag-

ments into the airway, which could occur with forceful

advancement of a larger endotracheal tube. With the Ain-

tree� catheter securely in place, the Shiley� tube was

removed, and the endotracheal tube was guided success-

fully over the catheter into the trachea (Figure, Panel C).

General anesthesia was induced after the airway was

secured, and the patient’s surgery and postoperative course

proceeded uneventfully.

Complications related to tracheostomy can be early or

late.1,2 Decannulation is usually an early event involving a

recently placed tracheostomy tube. Four weeks is generally

sufficient time for the tracheostomy tract to mature. In con-

trast, late decannulation is a rare complication since a mature

well-formed tracheostomy tract establishes airway patency.

When a patient with a tracheostomy presents for surgery,

positive pressure ventilation is usually required. This is

customarily achieved by removing the Shiley� tube andA. Truong, MD (&) � D.-T. Truong, MD

MD Anderson Cancer Center, Houston, TX, USA

e-mail: atruong@mdanderson.org

123

Can J Anesth/J Can Anesth (2011) 58:771–772

DOI 10.1007/s12630-011-9526-2

inserting a cuffed endotracheal tube into the stoma. Com-

plications may arise if it cannot be discerned that the

tracheostomy tube has migrated out of the airway, as it had in

this patient. Removal of the Shiley� tube followed by failure

to insert an endotracheal tube into the trachea may lead to

complete airway obstruction and creation of a false path.

Positive pressure ventilation may result in barotrauma,

subcutaneous and mediastinal emphysema, and

pneumothorax.

A case of obvious early tube displacement at seven days

after tracheostomy has been reported in which an Aintree�catheter was used for repositioning.3 Our case of malpo-

sition is rare because it occurred late, many months

following tracheostomy, and the fact that the patient was

completely asymptomatic made its presence deceptively

unapparent. Thus, regardless of the elapsed time after a

tracheostomy, it is imperative to rule out a malposition by

performing fibreoptic bronchoscopy. Visual confirmation

of correct catheter placement is important when dealing

with abnormal tissues. Use of an Aintree� catheter with a

fibreoptic bronchoscope to exchange the tracheostomy tube

for an endotracheal tube ensured successful airway control.

Disclosures We have no disclosures. We have no funding sources,

no commercial or non-commercial affiliations, or any other associa-

tions, such as consultancies.

Competing interests None declared.

References

1. Durbin CG Jr. Early complications of tracheostomy. Respir Care

2005; 50: 511-5.

2. Epstein SK. Late complications of tracheostomy. Respir Care

2005; 50: 542-9.

3. Rajendram R, McGuire N. Repositioning a displaced tracheostomy

tube with an Aintree intubation catheter mounted on a fibre-optic

bronchoscope. Br J Anaesth 2006; 97: 576-9.

Figure Panel A) Computed tomography scan of the tracheostomy

tube displaced from the airway by the tumour; Panel B) Broncho-

scopic view of the tracheostomy tube tip out of the airway; Panel C)

Successful endotracheal intubation through the tracheostomy site

b

772 A. Truong, D.-T. Truong

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