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Diaphragmatic rupture due to violent cough during tracheostomy
Auris Nasus Larynx 37 (2010) 121–124 www.elsevier.com/locate/anl
Diaphragmatic rupture due to violent cough during tracheostomy Hiroshi Nakanishi a,*, Satoshi Iwasaki b, Yasuhiro Ohkawa a, Hideo Nakazawa c, Hiroyuki Mineta a a
Department of Otolaryngology, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu 431-3192, Japan b Department of Otolaryngology, Hamamatsu Red Cross Hospital, 1088-1 Kobayashi, Hamakita-ku, Hamamatsu 434-8533, Japan c Department of General Surgery, Iwata City Hospital, 512-3 Ohkubo, Iwata 438-8550, Japan Received 24 December 2008; accepted 31 January 2009 Available online 6 May 2009
Abstract We present herein a rare case of diaphragmatic rupture due to violent coughing during tracheostomy. A 73-year-old man was admitted with cough, hoarseness and dysphagia caused by a huge laryngeal cancer obstructing the airways. Immediate emergency tracheostomy was performed, during which he experienced violent paroxysmal coughing, and he began to complain of right upper abdominal discomfort after tracheostomy. Chest radiography and computed tomography 4 days later showed right diaphragmatic rupture, through which small bowel loops had herniated into the right hemithorax. Diaphragmatic rupture with a 20-cm long fresh oblique tear was repaired through subsequent surgical treatment. Violent paroxysmal coughing during tracheostomy was considered likely to have caused this rare complication. # 2009 Elsevier Ireland Ltd. All rights reserved. Keywords: Tracheostomy; Complication; Diaphragmatic rupture; Cough
1. Introduction Tracheostomy is one of the most frequently performed surgical procedures in otolaryngology departments. While complications including hemorrhage, tube obstruction and tube displacement occur in 5–40% of tracheostomies [1], diaphragmatic rupture has not previously been reported. We offer the first report of diaphragmatic rupture caused by violent coughing during tracheostomy.
2. Case report A 73-year-old man presented to the Department of Otolaryngology complaining of cough, hoarseness and dysphagia with a 5-kg weight loss over the last 2 months. He admitted to alcohol abuse and smoking 20 cigarettes/day for the last 50 years. He had been diagnosed with asthma and treated for a month with inhaled glucocorticoids and * Corresponding author. Tel.: +81 53 435 2252; fax: +81 53 435 2253. E-mail address: [email protected] (H. Nakanishi).
theophyllines by a private practitioner without satisfactory symptom control. Laryngoscopic examination revealed a rough-surfaced exophytic lesion extending from the right to the left vocal cords. This lesion had infiltrated the epiglottic cartilage and subglottic space with almost complete obstruction of the airway. Contrast-enhanced computed tomography (CT) of the neck showed an enhanced mass 8 cm in diameter infiltrating the thyroid and cricoid cartilages (Fig. 1). Chest radiography (Fig. 2) and CT did not reveal lung disease. Laryngeal cancer obstructing the respiratory tract was diagnosed and he was admitted to hospital immediately. Emergency tracheostomy was performed using a standard technique with inverted U-shaped tracheal incision under local anesthesia. Although tracheostomy was performed with a meticulous technique, our patient experienced violent paroxysmal coughing during tracheostomy tube insertion, with aspiration of blood and mucus from the tracheal lumen. After tracheostomy, the patient began to complain of right upper abdominal discomfort. The abdomen was minimally distended with mild tenderness over the right upper abdomen. Temperature was 37.5 8C; blood pressure, 110/74 mmHg; heart rate, 84 beats/min; respiratory rate,
0385-8146/$ – see front matter # 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2009.01.015
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H. Nakanishi et al. / Auris Nasus Larynx 37 (2010) 121–124
Chest radiogram and CT were performed 4 days later. The results demonstrated right diaphragmatic rupture, mediastinal shift, and the presence of small bowel loops in the right hemithorax with pleural effusion (Figs. 3 and 4). Since chest radiography and CT showed normal results on admission and the patient had no history of thoracoabdominal trauma, non-traumatic diaphragmatic rupture was diagnosed and attributed to violent coughing during tracheostomy. He immediately underwent right laparotomy through a subcostal incision. An approximately 20-cm long, fresh, oblique tear extending from the anteromedial to the posterolateral segment of the right hemidiaphragm was found, through which the small intestine had herniated. The diaphragmatic rupture was repaired, and the loops of small intestine were replaced into the abdomen. Recovery was uneventful. Squamous cell carcinoma was diagnosed on historogical examination of the biopsied laryngeal tumor, so the patient was treated with radiotherapy for laryngeal carcinoma and discharged 3 months later.
Fig. 1. Cervical contrast-enhanced computed tomography revealing an enhanced mass 8 cm in diameter infiltrating the thyroid and cricoid cartilages.
3. Discussion
24 breaths/min; oxygen saturation, 94% in arterial blood analysis. Since vital signs were stable and complaints were mild, the patient was kept under observation. However, right upper abdominal discomfort persisted.
We presented herein a case of non-traumatic diaphragmatic rupture, which appeared likely to be caused by violent paroxysmal coughing during tracheostomy. Diaphragmatic rupture is typically caused by trauma: blunt trauma or penetrating trauma. Blunt trauma, often
Fig. 2. Chest radiography on admission showing no signs of lung disease.
Fig. 3. Chest radiography revealing small bowel loops in the right hemithorax with loss of right diaphragmatic definition.
H. Nakanishi et al. / Auris Nasus Larynx 37 (2010) 121–124
Fig. 4. Chest computed tomography showing right diaphragmatic rupture and mediastinal shift with pleural effusion.
caused by motor vehicle accidents, and penetrating trauma from gunshot or stab wounds account for 75% and 25% of cases of diaphragmatic rupture, respectively [2]. Approximately 1% or less of diaphragmatic ruptures are reportedly non-traumatic, and are also called spontaneous [3]. All nontraumatic diaphragmatic ruptures are caused by a sudden increase in intra-abdominal pressure caused by precipitating factors [4], including athletics, weight-lifting, dancing, parturition, violent emesis, defecation and coughing, with coughing as the most frequent cause [5]. However, at least some of the non-traumatic diaphragmatic ruptures reported to date appear to be related to preexisting diaphragmatic defects caused by some forgotten trauma in the past, so these events are not truly non-traumatic. In the present case, the patient had no history of thoracoabdominal trauma and chest radiography and CT on admission showed no signs of diaphragmatic defect or lung metastasis. In the operative view, the right diaphragm was thin, probably due to undernutrition resulting from dysphagia, and was freshly ruptured without the presence of fibrosis. Furthermore, despite meticulous technique, the patient had experienced violent paroxysmal coughing during tracheostomy, after which he began to complaint of right upper abdominal discomfort. These findings indicate that the diaphragm, which was structurally weak due to undernutrition, was non-traumatically ruptured by violent coughing during tracheostomy, resulting in herniation of the small intestine into the right hemithorax. Violent coughing is known to contribute to diaphragmatic rupture. In addition, various complications are associated with cough, including: syncope; rupture of subconjunctival, nasal, and anal veins; pneumomediastinum; pneumothorax; incontinence; muscle rupture; herniation of the lung through the intercostal space; and rib fracture [6]. Coughing is a three-phase exclusive motor act, characterized by deep inspiration (inspiratory phase) followed by forced expiration initially against a closed glottis (compressive phase), after
123
which the glottis opens and expiratory flow occurs (expulsive phase) [7]. During the compressive phase, expiratory muscles of the abdominal wall contract, pushing the diaphragm upward and the ribs inward and downward, causing sudden onset of high-intrapleural pressure [8]. This kind of opposing action and sudden change in intrapreutal pressure can cause the various complications described above. Tracheostomy, which has probably been known for at least 3000 years, is one of the most frequently performed procedures in otolaryngology departments [9]. Most retrospective studies have assessed the incidence of overall complications of tracheostomy as around 5–40%, with the agreed risk approximated at 15%. The most common complication is hemorrhage (3.7%), followed by tube obstruction (2.7%) and tube displacement (1.5%) [1]. The incidence of pneumothorax, tracheal stenosis, and tracheoesophageal fistula is <1% [10]. While numerous complications associated with tracheostomy have been reported to date, diaphragmatic rupture has not previously been described. Although diaphragmatic rupture complicated with tracheostomy might be very rare, a delayed or missed diagnosis could cause life-threatening sequelae. Early diagnosis, which depends on a high index of suspicion, and subsequent surgical treatment determine the successful treatment of diaphragmatic rupture [11]. Violent cough was induced during tracheostomy in the present case, and clinicians should bear in mind the possibility of cough causing non-traumatic diaphragmatic rupture.
4. Conclusion We have presented herein the first description of diaphragmatic rupture due to coughing during tracheostomy. Violent cough during tracheostomy may cause diaphragmatic rupture.
References [1] Bradley PJ. Management of the obstructed airway and tracheostomy. In: Kerr AG, editor. Scott–Brown’s otolaryngology. London: Butterworth & Heinmann; 1997. p. 5/7/7–17. [2] Shah R, Sabanathan S, Mearns AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg 1995;60:1444–9. [3] Kallay N, Crim L, Dunagan DP, Kavanagh PV, Meredith W, Haponik EF. Massive left diaphragmatic separation and rupture due to coughing during an asthma exacerbation. South Med J 2000;93:729–31. [4] Matsevych OY. Blunt diaphragmatic rupture: four year’s experience. Hernia 2008;12:73–8. [5] Gupta V, Singhal R, Ansari MZ. Spontaneous rupture of the diaphragm. Eur J Emerg Med 2005;12:43–4. [6] Kara E, Kaya Y, Zeybek R, Coskun T, Yavuz C. A case of diaphragmatic rupture complicated with lacerations of stomach and spleen caused by a violent cough presenting with mediastinal shift. Ann Acad Med Singapore 2004;33:649–50.
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[7] Fontana GA. Before we get started: what is a cough? Lung 2008; 186:S3–6. [8] George L, Rehman SU, Khan FA. Diaphragmatic rupture: a complication of violent cough. Chest 2000;117:1200–1. [9] McClelland MA. Tracheostomy: its management and alternatives. Proc R Soc Med 1972;65:401–4.
[10] Goldenberg D, Ari EG, Golz A, Danino J, Netzer A, Joachims HZ. Tracheotomy complications: a retrospective study of 1130 cases. Otolaryngol Head Neck Surg 2000;123:495–500. [11] Haciibrahimoglu G, Solak O, Olcmen A, Bedirhan MA, Solmezer N, Gurses A. Management of traumatic diaphragmatic rupture. Surg Today 2004;34:111–4.
Diaphragmatic rupture due to violent cough during tracheostomy Hiroshi Nakanishi a,*, Satoshi Iwasaki b, Yasuhiro Ohkawa a, Hideo Nakazawa c, Hiroyuki Mineta a a
Department of Otolaryngology, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu 431-3192, Japan b Department of Otolaryngology, Hamamatsu Red Cross Hospital, 1088-1 Kobayashi, Hamakita-ku, Hamamatsu 434-8533, Japan c Department of General Surgery, Iwata City Hospital, 512-3 Ohkubo, Iwata 438-8550, Japan Received 24 December 2008; accepted 31 January 2009 Available online 6 May 2009
Abstract We present herein a rare case of diaphragmatic rupture due to violent coughing during tracheostomy. A 73-year-old man was admitted with cough, hoarseness and dysphagia caused by a huge laryngeal cancer obstructing the airways. Immediate emergency tracheostomy was performed, during which he experienced violent paroxysmal coughing, and he began to complain of right upper abdominal discomfort after tracheostomy. Chest radiography and computed tomography 4 days later showed right diaphragmatic rupture, through which small bowel loops had herniated into the right hemithorax. Diaphragmatic rupture with a 20-cm long fresh oblique tear was repaired through subsequent surgical treatment. Violent paroxysmal coughing during tracheostomy was considered likely to have caused this rare complication. # 2009 Elsevier Ireland Ltd. All rights reserved. Keywords: Tracheostomy; Complication; Diaphragmatic rupture; Cough
1. Introduction Tracheostomy is one of the most frequently performed surgical procedures in otolaryngology departments. While complications including hemorrhage, tube obstruction and tube displacement occur in 5–40% of tracheostomies [1], diaphragmatic rupture has not previously been reported. We offer the first report of diaphragmatic rupture caused by violent coughing during tracheostomy.
2. Case report A 73-year-old man presented to the Department of Otolaryngology complaining of cough, hoarseness and dysphagia with a 5-kg weight loss over the last 2 months. He admitted to alcohol abuse and smoking 20 cigarettes/day for the last 50 years. He had been diagnosed with asthma and treated for a month with inhaled glucocorticoids and * Corresponding author. Tel.: +81 53 435 2252; fax: +81 53 435 2253. E-mail address: [email protected] (H. Nakanishi).
theophyllines by a private practitioner without satisfactory symptom control. Laryngoscopic examination revealed a rough-surfaced exophytic lesion extending from the right to the left vocal cords. This lesion had infiltrated the epiglottic cartilage and subglottic space with almost complete obstruction of the airway. Contrast-enhanced computed tomography (CT) of the neck showed an enhanced mass 8 cm in diameter infiltrating the thyroid and cricoid cartilages (Fig. 1). Chest radiography (Fig. 2) and CT did not reveal lung disease. Laryngeal cancer obstructing the respiratory tract was diagnosed and he was admitted to hospital immediately. Emergency tracheostomy was performed using a standard technique with inverted U-shaped tracheal incision under local anesthesia. Although tracheostomy was performed with a meticulous technique, our patient experienced violent paroxysmal coughing during tracheostomy tube insertion, with aspiration of blood and mucus from the tracheal lumen. After tracheostomy, the patient began to complain of right upper abdominal discomfort. The abdomen was minimally distended with mild tenderness over the right upper abdomen. Temperature was 37.5 8C; blood pressure, 110/74 mmHg; heart rate, 84 beats/min; respiratory rate,
0385-8146/$ – see front matter # 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.anl.2009.01.015
122
H. Nakanishi et al. / Auris Nasus Larynx 37 (2010) 121–124
Chest radiogram and CT were performed 4 days later. The results demonstrated right diaphragmatic rupture, mediastinal shift, and the presence of small bowel loops in the right hemithorax with pleural effusion (Figs. 3 and 4). Since chest radiography and CT showed normal results on admission and the patient had no history of thoracoabdominal trauma, non-traumatic diaphragmatic rupture was diagnosed and attributed to violent coughing during tracheostomy. He immediately underwent right laparotomy through a subcostal incision. An approximately 20-cm long, fresh, oblique tear extending from the anteromedial to the posterolateral segment of the right hemidiaphragm was found, through which the small intestine had herniated. The diaphragmatic rupture was repaired, and the loops of small intestine were replaced into the abdomen. Recovery was uneventful. Squamous cell carcinoma was diagnosed on historogical examination of the biopsied laryngeal tumor, so the patient was treated with radiotherapy for laryngeal carcinoma and discharged 3 months later.
Fig. 1. Cervical contrast-enhanced computed tomography revealing an enhanced mass 8 cm in diameter infiltrating the thyroid and cricoid cartilages.
3. Discussion
24 breaths/min; oxygen saturation, 94% in arterial blood analysis. Since vital signs were stable and complaints were mild, the patient was kept under observation. However, right upper abdominal discomfort persisted.
We presented herein a case of non-traumatic diaphragmatic rupture, which appeared likely to be caused by violent paroxysmal coughing during tracheostomy. Diaphragmatic rupture is typically caused by trauma: blunt trauma or penetrating trauma. Blunt trauma, often
Fig. 2. Chest radiography on admission showing no signs of lung disease.
Fig. 3. Chest radiography revealing small bowel loops in the right hemithorax with loss of right diaphragmatic definition.
H. Nakanishi et al. / Auris Nasus Larynx 37 (2010) 121–124
Fig. 4. Chest computed tomography showing right diaphragmatic rupture and mediastinal shift with pleural effusion.
caused by motor vehicle accidents, and penetrating trauma from gunshot or stab wounds account for 75% and 25% of cases of diaphragmatic rupture, respectively [2]. Approximately 1% or less of diaphragmatic ruptures are reportedly non-traumatic, and are also called spontaneous [3]. All nontraumatic diaphragmatic ruptures are caused by a sudden increase in intra-abdominal pressure caused by precipitating factors [4], including athletics, weight-lifting, dancing, parturition, violent emesis, defecation and coughing, with coughing as the most frequent cause [5]. However, at least some of the non-traumatic diaphragmatic ruptures reported to date appear to be related to preexisting diaphragmatic defects caused by some forgotten trauma in the past, so these events are not truly non-traumatic. In the present case, the patient had no history of thoracoabdominal trauma and chest radiography and CT on admission showed no signs of diaphragmatic defect or lung metastasis. In the operative view, the right diaphragm was thin, probably due to undernutrition resulting from dysphagia, and was freshly ruptured without the presence of fibrosis. Furthermore, despite meticulous technique, the patient had experienced violent paroxysmal coughing during tracheostomy, after which he began to complaint of right upper abdominal discomfort. These findings indicate that the diaphragm, which was structurally weak due to undernutrition, was non-traumatically ruptured by violent coughing during tracheostomy, resulting in herniation of the small intestine into the right hemithorax. Violent coughing is known to contribute to diaphragmatic rupture. In addition, various complications are associated with cough, including: syncope; rupture of subconjunctival, nasal, and anal veins; pneumomediastinum; pneumothorax; incontinence; muscle rupture; herniation of the lung through the intercostal space; and rib fracture [6]. Coughing is a three-phase exclusive motor act, characterized by deep inspiration (inspiratory phase) followed by forced expiration initially against a closed glottis (compressive phase), after
123
which the glottis opens and expiratory flow occurs (expulsive phase) [7]. During the compressive phase, expiratory muscles of the abdominal wall contract, pushing the diaphragm upward and the ribs inward and downward, causing sudden onset of high-intrapleural pressure [8]. This kind of opposing action and sudden change in intrapreutal pressure can cause the various complications described above. Tracheostomy, which has probably been known for at least 3000 years, is one of the most frequently performed procedures in otolaryngology departments [9]. Most retrospective studies have assessed the incidence of overall complications of tracheostomy as around 5–40%, with the agreed risk approximated at 15%. The most common complication is hemorrhage (3.7%), followed by tube obstruction (2.7%) and tube displacement (1.5%) [1]. The incidence of pneumothorax, tracheal stenosis, and tracheoesophageal fistula is <1% [10]. While numerous complications associated with tracheostomy have been reported to date, diaphragmatic rupture has not previously been described. Although diaphragmatic rupture complicated with tracheostomy might be very rare, a delayed or missed diagnosis could cause life-threatening sequelae. Early diagnosis, which depends on a high index of suspicion, and subsequent surgical treatment determine the successful treatment of diaphragmatic rupture [11]. Violent cough was induced during tracheostomy in the present case, and clinicians should bear in mind the possibility of cough causing non-traumatic diaphragmatic rupture.
4. Conclusion We have presented herein the first description of diaphragmatic rupture due to coughing during tracheostomy. Violent cough during tracheostomy may cause diaphragmatic rupture.
References [1] Bradley PJ. Management of the obstructed airway and tracheostomy. In: Kerr AG, editor. Scott–Brown’s otolaryngology. London: Butterworth & Heinmann; 1997. p. 5/7/7–17. [2] Shah R, Sabanathan S, Mearns AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg 1995;60:1444–9. [3] Kallay N, Crim L, Dunagan DP, Kavanagh PV, Meredith W, Haponik EF. Massive left diaphragmatic separation and rupture due to coughing during an asthma exacerbation. South Med J 2000;93:729–31. [4] Matsevych OY. Blunt diaphragmatic rupture: four year’s experience. Hernia 2008;12:73–8. [5] Gupta V, Singhal R, Ansari MZ. Spontaneous rupture of the diaphragm. Eur J Emerg Med 2005;12:43–4. [6] Kara E, Kaya Y, Zeybek R, Coskun T, Yavuz C. A case of diaphragmatic rupture complicated with lacerations of stomach and spleen caused by a violent cough presenting with mediastinal shift. Ann Acad Med Singapore 2004;33:649–50.
124
H. Nakanishi et al. / Auris Nasus Larynx 37 (2010) 121–124
[7] Fontana GA. Before we get started: what is a cough? Lung 2008; 186:S3–6. [8] George L, Rehman SU, Khan FA. Diaphragmatic rupture: a complication of violent cough. Chest 2000;117:1200–1. [9] McClelland MA. Tracheostomy: its management and alternatives. Proc R Soc Med 1972;65:401–4.
[10] Goldenberg D, Ari EG, Golz A, Danino J, Netzer A, Joachims HZ. Tracheotomy complications: a retrospective study of 1130 cases. Otolaryngol Head Neck Surg 2000;123:495–500. [11] Haciibrahimoglu G, Solak O, Olcmen A, Bedirhan MA, Solmezer N, Gurses A. Management of traumatic diaphragmatic rupture. Surg Today 2004;34:111–4.