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Management of closed tracheal perforation following blunt trauma
Otolaryngology–Head and Neck Surgery (2009) 141, 661-662
CASE REPORT
Management of closed tracheal perforation following blunt trauma John O’Callaghan, MBBS, Siew Min Keh, MBBS, FRCS, and Alwyn D’Souza, MBBS, FRCS, London, United Kingdom No sponsorships or competing interests have been disclosed for this article.
T
racheal perforation is a recognized complication of both endotracheal intubation and emergency tracheostomy. Less commonly, it can result from trauma to the chest, head, or neck. Injuries to the tracheobronchial tree are rare but life threatening; 78 percent die before admission,1 and 21 percent of those admitted die within two hours.2 We describe the conservative management of a case of a closed tracheal perforation following blunt trauma. A 52-year-old man was found unconscious on the floor at home by his family and was brought to the emergency department. On arrival he was maintaining his own airway, but was tachypneic. He had extensive subcutaneous emphysema of the neck and chest, with reduced air entry and breath sounds bilaterally. He was hemodynamically stable. Chest x-ray demonstrated pneumomediastinum and bilateral pneumothoraces; the right side required insertion of a chest drain. The exact mechanism of injury was unclear; the patient had no penetrating wounds and had lost consciousness at the scene. Alert and stable, the patient had an urgent CT of the neck and chest. This showed an irregularity of the anterior wall of the trachea at the level of the fourth cervical vertebra, with pockets of gas anteriorly, suggestive of a closed tracheal perforation at this level. Despite the significant injuries to our patient, his airway was not under immediate threat, and he remained clinically stable. The tracheal perforation was therefore managed without intubation or surgery. He made a good recovery and was discharged after the pneumothoraces and subcutaneous emphysema had resolved. He was well at follow-up in clinic.
DISCUSSION A review of 265 blunt tracheobronchial injuries identified that motor vehicle accidents were the most frequent mechanism of injury (59%), followed by crush injuries (25%).3
The same review showed that the right bronchus is more frequently the site of perforation than the left (47% and 32%, respectively), and 76 percent of injuries are within 2 cm of the carina. Mortality has been shown to be higher with tracheal injuries (26%) than bronchial injuries (16% right, 8% left).3 Perforations that are diagnosed early are also associated with a higher mortality. It is speculated that this is due to the presence of multiple associated injuries.3 Our patient presented with a rare injury, an anterior perforation of the cervical trachea following blunt injury. Management of tracheal perforations may be surgical or conservative. Surgical repair is generally advised; tracheal perforations are associated with a 10-fold increase in mortality if managed conservatively (6% to 66%).3 The mechanism of injury and location of tracheal perforations influence the appropriate surgical management. This includes nonabsorbable suture closure of perforations and end-to-end anastomosis for complete transections. An injured bronchus may require resection including distal parenchyma resection; this is associated with higher mortality than repair alone.3 A series of five tracheal perforations (all closed injuries) demonstrated that defects in the upper third of the trachea could be managed with intubation alone.4 Defects were bridged with endotracheal tubes and the cuff inflated distal to the perforation. No stenosis or mediastinitis was reported. We were prepared to intubate our patient should it be required, and ideally bridge the defect. If an airway could not be maintained in this manner, then an emergency tracheostomy would have been considered, albeit with the risk of further tracheal trauma. A recent retrospective review of 33 tracheobronchial injuries found that in the absence of progressive deterioration, open injuries, or mediastinitis, conservative management was not associated with increased mortality.5 Injuries to the trachea or bronchi can be rapidly fatal and are not always obvious on presentation. Our patient presented with the three clinical signs most commonly associated with blunt tracheobronchial perforations: tachypnea, diminished breath sounds, and subcutaneous emphysema.
Received December 26, 2008; revised April 1, 2009; accepted May 8, 2009.
0194-5998/$36.00 © 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2009.05.007
662
Otolaryngology–Head and Neck Surgery, Vol 141, No 5, November 2009
AUTHOR INFORMATION From University Hospital Lewisham, London, United Kingdom. Corresponding author: John O’Callaghan, MBBS, ENT Department, University Hospital Lewisham, Lewisham, London SE13 6LH, United Kingdom. E-mail address: [email protected].
AUTHOR CONTRIBUTIONS John O’Callaghan, author, literature review; Siew Min Keh, author, literature review; Alwyn D’Souza, editorial.
Figure 1 CT scan of the neck showed extensive subcutaneous emphysema with an anterior perforation of the trachea at the level of the fourth cervical vertebra.
DISCLOSURES Competing interests: None. Sponsorships: None.
However, all three signs have low sensitivity (22%, 22%, and 20%, respectively),5 and the first two have low specificity in a trauma patient, so a high degree of clinical suspicion is important. Plain chest radiographs can hint at the diagnosis, but CT scan and/or bronchoscopy is necessary. The management of these injuries is currently primarily surgical; however, there is limited evidence that certain injuries may be managed with intubation or observation alone, namely those that are stable and involve solely the tracheal membrane. (Fig 1). Under the terms of the Governance Arrangements for Research Ethics Committees in the UK, this paper did not need to be reviewed by the Institutional Review Board.
REFERENCES 1. Ecker RR, Libertini RV, Rea WJ, et al. Injuries of the trachea and bronchi. Ann Thorac Surg 1971;11:289 –98. 2. Eijgelaar A, van der Heide HJN. A reliable early symptom of bronchial or tracheal rupture. Thorax 1970;25:120 –5. 3. Kiser A, O’Brien S, Detterbeck F. Blunt tracheobronchial injuries: treatment outcomes. Ann Thorac Surg 2001;71:2059 – 65. 4. Beiderlinden M, Adamzik M, Peters J. Conservative treatment of tracheal injuries. Anesth Analg 2005;100:210 – 4. 5. Gomez-Caro A, Ausin P, Moradiellos FJ, et al. Role of conservative medical management of tracheobronchial injuries. J Trauma 2006;61: 1426 –35.
CASE REPORT
Management of closed tracheal perforation following blunt trauma John O’Callaghan, MBBS, Siew Min Keh, MBBS, FRCS, and Alwyn D’Souza, MBBS, FRCS, London, United Kingdom No sponsorships or competing interests have been disclosed for this article.
T
racheal perforation is a recognized complication of both endotracheal intubation and emergency tracheostomy. Less commonly, it can result from trauma to the chest, head, or neck. Injuries to the tracheobronchial tree are rare but life threatening; 78 percent die before admission,1 and 21 percent of those admitted die within two hours.2 We describe the conservative management of a case of a closed tracheal perforation following blunt trauma. A 52-year-old man was found unconscious on the floor at home by his family and was brought to the emergency department. On arrival he was maintaining his own airway, but was tachypneic. He had extensive subcutaneous emphysema of the neck and chest, with reduced air entry and breath sounds bilaterally. He was hemodynamically stable. Chest x-ray demonstrated pneumomediastinum and bilateral pneumothoraces; the right side required insertion of a chest drain. The exact mechanism of injury was unclear; the patient had no penetrating wounds and had lost consciousness at the scene. Alert and stable, the patient had an urgent CT of the neck and chest. This showed an irregularity of the anterior wall of the trachea at the level of the fourth cervical vertebra, with pockets of gas anteriorly, suggestive of a closed tracheal perforation at this level. Despite the significant injuries to our patient, his airway was not under immediate threat, and he remained clinically stable. The tracheal perforation was therefore managed without intubation or surgery. He made a good recovery and was discharged after the pneumothoraces and subcutaneous emphysema had resolved. He was well at follow-up in clinic.
DISCUSSION A review of 265 blunt tracheobronchial injuries identified that motor vehicle accidents were the most frequent mechanism of injury (59%), followed by crush injuries (25%).3
The same review showed that the right bronchus is more frequently the site of perforation than the left (47% and 32%, respectively), and 76 percent of injuries are within 2 cm of the carina. Mortality has been shown to be higher with tracheal injuries (26%) than bronchial injuries (16% right, 8% left).3 Perforations that are diagnosed early are also associated with a higher mortality. It is speculated that this is due to the presence of multiple associated injuries.3 Our patient presented with a rare injury, an anterior perforation of the cervical trachea following blunt injury. Management of tracheal perforations may be surgical or conservative. Surgical repair is generally advised; tracheal perforations are associated with a 10-fold increase in mortality if managed conservatively (6% to 66%).3 The mechanism of injury and location of tracheal perforations influence the appropriate surgical management. This includes nonabsorbable suture closure of perforations and end-to-end anastomosis for complete transections. An injured bronchus may require resection including distal parenchyma resection; this is associated with higher mortality than repair alone.3 A series of five tracheal perforations (all closed injuries) demonstrated that defects in the upper third of the trachea could be managed with intubation alone.4 Defects were bridged with endotracheal tubes and the cuff inflated distal to the perforation. No stenosis or mediastinitis was reported. We were prepared to intubate our patient should it be required, and ideally bridge the defect. If an airway could not be maintained in this manner, then an emergency tracheostomy would have been considered, albeit with the risk of further tracheal trauma. A recent retrospective review of 33 tracheobronchial injuries found that in the absence of progressive deterioration, open injuries, or mediastinitis, conservative management was not associated with increased mortality.5 Injuries to the trachea or bronchi can be rapidly fatal and are not always obvious on presentation. Our patient presented with the three clinical signs most commonly associated with blunt tracheobronchial perforations: tachypnea, diminished breath sounds, and subcutaneous emphysema.
Received December 26, 2008; revised April 1, 2009; accepted May 8, 2009.
0194-5998/$36.00 © 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2009.05.007
662
Otolaryngology–Head and Neck Surgery, Vol 141, No 5, November 2009
AUTHOR INFORMATION From University Hospital Lewisham, London, United Kingdom. Corresponding author: John O’Callaghan, MBBS, ENT Department, University Hospital Lewisham, Lewisham, London SE13 6LH, United Kingdom. E-mail address: [email protected].
AUTHOR CONTRIBUTIONS John O’Callaghan, author, literature review; Siew Min Keh, author, literature review; Alwyn D’Souza, editorial.
Figure 1 CT scan of the neck showed extensive subcutaneous emphysema with an anterior perforation of the trachea at the level of the fourth cervical vertebra.
DISCLOSURES Competing interests: None. Sponsorships: None.
However, all three signs have low sensitivity (22%, 22%, and 20%, respectively),5 and the first two have low specificity in a trauma patient, so a high degree of clinical suspicion is important. Plain chest radiographs can hint at the diagnosis, but CT scan and/or bronchoscopy is necessary. The management of these injuries is currently primarily surgical; however, there is limited evidence that certain injuries may be managed with intubation or observation alone, namely those that are stable and involve solely the tracheal membrane. (Fig 1). Under the terms of the Governance Arrangements for Research Ethics Committees in the UK, this paper did not need to be reviewed by the Institutional Review Board.
REFERENCES 1. Ecker RR, Libertini RV, Rea WJ, et al. Injuries of the trachea and bronchi. Ann Thorac Surg 1971;11:289 –98. 2. Eijgelaar A, van der Heide HJN. A reliable early symptom of bronchial or tracheal rupture. Thorax 1970;25:120 –5. 3. Kiser A, O’Brien S, Detterbeck F. Blunt tracheobronchial injuries: treatment outcomes. Ann Thorac Surg 2001;71:2059 – 65. 4. Beiderlinden M, Adamzik M, Peters J. Conservative treatment of tracheal injuries. Anesth Analg 2005;100:210 – 4. 5. Gomez-Caro A, Ausin P, Moradiellos FJ, et al. Role of conservative medical management of tracheobronchial injuries. J Trauma 2006;61: 1426 –35.