Airway Management for Tracheal Perforation After Left Hemi-Thyroid Lobectomy: A Case Report

Introduction

Tracheal perforation is a rare but serious complication that can occur after thyroid surgery, airway trauma, inhalation injury, or infection [1–3]. Although its incidence after thyroid surgery is low (0.06%) [3], surgical intervention under general anesthesia is often required [4,5]. Managing the airway in these patients presents a significant challenge, as tracheal perforation is frequently associated with a difficult airway, and no standard technique exists for securing the airway in cases of airway interruption.

Awake fiberoptic intubation is particularly beneficial in these cases, as it enables real-time airway visualization while maintaining spontaneous ventilation, minimizing the risk of exacerbating tracheal injury. This technique is widely recommended for securing the airway in patients with tracheal trauma or perforation, where conventional intubation methods pose serious risks [1,6].

This report presents a case of successful airway management for general anesthesia in a patient who developed tracheal perforation and necrosis after thyroid surgery, and aims to contribute to the existing literature.

Case Report

A 65-year-old woman (height: 166 cm, weight: 50 kg) with a thyroid tumor and hyperlipidemia underwent a left hemi-thyroid lobectomy. The pathology report at that time indicated a benign tumor. She had no history of radiation therapy or neck trauma before or after the surgery. Six months after surgery, she reported a sore throat and neck swelling. A computed tomography scan revealed tracheal perforation (Figure 1A) on the left side, just below the glottis and subcutaneous emphysema (Figure 1B). Bronchoscopy confirmed tracheal perforation on the left side below the glottis, surrounded by necrotic tissues (Figure 1C). The tracheal cartilage was barely exposed, and the mucosa was hemorrhagic (Figure 1D). The diameter of perforation was 3 cm, located 7 cm above the tracheal bifurcation. She was scheduled for urgent tracheostomy under general anesthesia.

At the preoperative multidisciplinary meeting, we discussed 3 possible airway management methods (awake fiberoptic intubation by the anesthesiologist, awake tracheostomy by the otolaryngologist in case orotracheal intubation fails, or extracorporeal membrane oxygenation by the cardiologist). Because the distance from the perforation site to the tracheal bifurcation was sufficient to place the tracheal tube, awake fiberoptic intubation was chosen to secure the airway for general anesthesia.

As a backup plan, the surgeon was on stand-by in the operating theater, prepared to promptly perform an awake tracheotomy if the clinical situation necessitated it. She received 4% lidocaine from Jackson’s spray for throat anesthesia before the bronchoscopy. She also received incremental doses of 200 μg intravenous fentanyl. The bronchoscope was advanced distal to the perforation site, located below the vocal cords (Figure 2A, Video 1). The endotracheal tube was gently inserted over the bronchoscope, with the cuff avoiding the perforation, and the tip of the tube was placed just above the tracheal bifurcation (Figure 2B, 2C). Once the cuff was secured, general anesthesia was initiated, and tracheostomy was performed from the surgical field. After completion of surgery, she emerged from general anesthesia and was transferred to the ICU. Postoperative histological analysis of the tissue obtained during the tracheostomy revealed squamous cell carcinoma, suggesting that tracheal perforation and necrosis may have been caused by malignant infiltration.

Discussion

We report a case of tracheal perforation following left hemithyroid lobectomy, requiring general anesthesia for the tracheal repair. Airway management was successfully achieved using awake fiberoptic intubation, ensuring the cuff was positioned distal to the site of perforation.

Careful assessment of the airway and a tailored approach to tracheal intubation are critical in tracheal injuries. Positive-pressure mask ventilation should be avoided, as it can exacerbate conditions such as subcutaneous emphysema, pneumothorax, or pneumomediastinum [7]. While rapid-sequence induction may appear advantageous in avoiding mask ventilation, it risks improper tracheal tube placement, especially in the presence of tracheal perforation [8]. These risks highlight the importance of our chosen strategy: awake fiberoptic intubation under spontaneous breathing, which is a technique recommended for managing traumatic tracheal perforations [1]. We considered alternative strategies such as awake tracheostomy and extracorporeal membrane oxygenation. While awake tracheostomy avoids the need for positive-pressure ventilation, it can be distressing and technically challenging in uncooperative patients. Extracorporeal membrane oxygenation offers oxygenation support without airway reliance, but requires specialized equipment and personnel, limiting its practicality as a first-line approach. Given the anatomical distance between the perforation and the tracheal bifurcation, awake fiberoptic intubation was the safest and most controlled strategy in our patient.

Awake fiberoptic intubation provides clear visualization of the perforation site, enabling precise tracheal tube placement. However, tracheal bleeding remains a significant challenge, as it can impair visualization and complicate intubation. This was a concern in our patient, who exhibited fragile and hemorrhagic tracheal mucosa during preoperative bronchoscopy. To minimize bleeding-related visualization issues, we advanced the bronchoscope as gently as possible to avoid additional trauma to the tracheal mucosa. Suctioning was performed intermittently rather than continuously to prevent mucosal irritation while maintaining a clear view. Although topical vasoconstrictors such as epinephrine or tranexamic acid have been reported as useful for reducing airway bleeding in similar cases [9], we did not use them in this case. Their use might have been a reasonable option to further improve visualization and minimize bleeding. Instead, a backup plan was in place, including immediate transition to awake tracheostomy if bleeding significantly impaired visualization. Strategies to mitigate such risks include preparation for alternative airway access techniques, consistent with the American Society of Anesthesiologists Practice Guidelines for the Management of the Difficult Airway [10] and established algorithms for tracheal laceration management [11]. Before advancing to airway access in this patient, we discussed the possibility of a tracheotomy and extracorporeal membrane oxygenation with the multidisciplinary team in case of failure of awake intubation with bronchoscopy. A multidisciplinary team reviewed these options preoperatively, ensuring preparedness in the event of intubation failure.

Previous reports have described cases where initial intubation attempts failed, necessitating alternative strategies such as fiberoptic-guided intubation or surgical tracheostomy [2,8]. In contrast, this case demonstrates the feasibility of primary awake fiberoptic intubation, avoiding surgical intervention. The perforation’s anatomical location allowed safe distal tube placement, and a preplanned multidisciplinary approach ensured successful non-invasive management.

The reported risk factors for delayed tracheal perforation, which most commonly occurs within 40 days postoperatively, include large thyroid nodules, prolonged preoperative steroid use, previous radiation therapy, and intraoperative thermal injury from electrocautery [4]. However, in this case, the patient initially underwent thyroidectomy for a presumed benign nodule, and the perforation occurred 6 months later. Postoperative histological analysis of the tissue obtained during the tracheostomy revealed squamous cell carcinoma, suggesting that malignancy-related tracheal necrosis may have contributed to its occurrence.

Conclusions

This case demonstrates successful airway management of tracheal perforation using awake fiberoptic intubation. This approach minimized complications such as subcutaneous emphysema and pneumothorax, reinforcing its role as a safe and effective technique. These findings support the use of awake intubation in complex airway scenarios and highlight the importance of a multidisciplinary approach.