DOI: https://doi.org/10.21203/rs.3.rs-1989771/v1
Background: In the post-intubation period, laryngeal edema is one of the most severe complications, which can cause significant morbidity and even death. Herein, we report a case in which we performed a temporary tracheostomy during surgery because of the risk of postoperative laryngeal edema, successfully avoiding post-intubation laryngeal edema complications.
Case presentation: A 78-year-old man underwent surgery for left upper lobe lung cancer. He had a history of chemoradiotherapy for laryngeal cancer, bronchial asthma, and chronic obstructive pulmonary disease. He was diagnosed with grade 1 laryngeal edema using computed tomography, and there was a risk of the post-intubation laryngeal edema. Additionally, there was a decrease in laryngeal and pulmonary functions; therefore, postoperative aspiration pneumonia was judged to be a fatal risk. A temporary tracheostomy was performed during surgery to avoid postoperative intubation laryngeal edema. He was found to have exacerbated laryngeal edema; a serious complication of airway stenosis.
Conclusion: Temporary tracheostomy should be considered to avoid airway stenosis due to post-intubation laryngeal edema in patients with laryngeal edema after radiotherapy.
Laryngeal edema commonly occurs after tracheal intubation [1]. Post-intubation laryngeal edema (PILE) is severe complication, that causes significant morbidity and death [1, 2]. Urgent treatment, such as tracheostomy may be required depending on the degree of stenosis. In thoracic surgery, a double-lumen tube (DLT) is used for differential lung ventilation, but the DLT is thicker than a single lumen tube, and there are reports of PILE or airway stenosis [2–6]. We report a case where PILE complications were successfully avoided by performing a temporary tracheostomy (TT) during surgery in a patient with a high risk of postoperative edema.
A 78-year-old man was found to have a nodule in the upper lobe of the left lung. The patient was previously treated with chemoradiotherapy (CRT) for stage III laryngeal cancer. Additionally, he had a history of bronchial asthma and chronic obstructive pulmonary disease. Squamous cell carcinoma was diagnosed by transbronchial lung biopsy and staged as cT1bN0M0, stage IA2 lung cancer. Therefore, the patient was referred for surgery. A chest computed tomography (CT) scan showed a solid nodule shadow in the left ventral segment measuring 1.5 × 1.4 cm (Fig. 1a) without any lymphadenopathy. CT showed edema around the arytenoid and vocal cords (Fig. 1b-1d) and the inner tracheal diameter at the cricoid level was 11.5 × 6.5 mm. 2-deoxy-2-(18F)-fluorodeoxyglucose positron emission tomography revealed tracer accumulation in the lung nodule. There was no accumulation suggesting local recurrence of laryngeal cancer. Laryngoscopy showed swelling of both vestibular folds, whitening of the mucosa, and edema from the oropharynx to the hypopharynx [grade 1 laryngeal edema in the radiation therapy oncology group (RTOG)]. The vocal cords had good mobility, but poor laryngeal elevation and mild saliva retention with diminished laryngeal perception were observed (Fig. 2a, 2b). The head and neck surgeon determined that there was a risk of postoperative exacerbation of laryngopharyngeal edema due to intubation. The forced expiratory volume in one second (FEV1) was 1050 mL, %FEV1 was 42.6% and FEV1/forced vital capacity (FEV1%) was 34.3% showing a remarkable decrease. There was a decrease in laryngeal and pulmonary functions; therefore, postoperative aspiration pneumonia was judged to be a fatal risk. At a conference including a thoracic surgeon, head and neck surgeon, and anesthetist, it was determined that the patient was at risk of potentially fatal postoperative aspiration pneumonia and laryngeal edema which could be exacerbated postoperatively. Accordingly, TT was performed during surgery.
To prevent bronchospasm, 30 mg of prednisolone was infused preoperatively. The 35 French DLT was inserted without resistance. Left upper division segmentectomy and nodal dissection 1b were performed in the right lateral position. Then, a tracheostomy was performed in the supine position. Duration of the lung surgery, tracheostomy, and anesthesia was 137 min, 22 min, and 239 min, respectively. After tracheostomy, the larynx examination revealed that the laryngeal edema was worse than before intubation.
On the second postoperative day (POD), laryngoscopy showed swelling and stenosis of the glottis from the arytenoid muscle, and moderate saliva retention and aspiration were observed (RTOG grade 3) (Fig. 2c, 2d). A videoendoscopic evaluation of swallowing performed on POD 4 revealed a decrease in pharyngeal contractility; therefore, a swallowing training diet was started. The chest drainage tube was removed on POD 7 because of prolonged air leakage. We determined that postoperative swallowing function training and respiratory rehabilitation were necessary and transferred to the Head and Neck Surgery Department to continue rehabilitation. The swelling of the larynx gradually improved on POD 16 (RTOG grade 2) (Fig. 2e, 2f). The tracheostomy was closed on POD 28 and the patient was discharged on POD 30.
Traumatic laryngitis is a complication associated with DLT placement [7]. PILE results from trauma to the laryngeal mucosa causing mucosal edema and swelling. Fifty-four percent of the patients who have undergone intubation or tracheostomy have subvocal ulcers, and 93% have mucosal inflammation or edema [1]. Therefore, the DLT should be of appropriate size and according to the patient’s sex, physique, and imaging data (CT or chest radiography) [7, 8]
Females have anatomically smaller airways than males and therefore are at a higher risk of PILE [7, 9]. There are 11 reported cases of PILE after lung surgery using DLT (including ours), in the English and Japanese literature (Table 1). Of these, 10 were of female patients and seven cases with less than 150 cm length. There was resistance during intubation in eight cases, and in four cases, the DLT size was reduced.
Our patient was a male with an adequately sized DLT and smooth intubation. However, this patient had previously been treated with CRT, and larynx edema was noted preoperatively. Although radiotherapy (RT) allows laryngeal preservation in patients with head and neck cancers, it may induce salivary or laryngopharyngeal dysfunction. Fibrotic changes following RT may lead to lymphatic vessel obstruction, causing edema, particularly in the supraglottic areas [10]. Additionally, the patient had a history of asthma and atopy, which can predispose him to an increased inflammatory response, resulting in severe edema and swelling [2]. Furthermore, decreased laryngeal function is a risk factor for severe aspiration pneumonia. In this case, a decrease FEV1, %FEV1 and FEV1% was observed, and postoperative aspiration pneumonia was considered extremely fatal. Therefore, we recommend that TT may be considered to avoid airway stenosis due to PILE and postoperative aspiration pneumonia if there is pre-existing edema, a predisposition to allergies, and a decrease in laryngeal and pulmonary functions.
In conclusion, TT may be an important option for postoperative airway management in patients with laryngeal edema, airway stenosis, and decreased laryngeal function due to treatment for laryngeal cancer.
Chemoradiotherapy
Computed tomography
Double-lumen tube
Forced expiratory volume in one second
FEV1/forced vital capacity, PILE:Post-intubation laryngeal edema
Postoperative day
Radiotherapy
Radiation therapy oncology group
Temporary tracheostomy
Ethics approval and consent to participate
Not applicable
Consent for publication
Written informed consent was obtained from the patient to publish this report and its accompanying images.
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
Competing interests
All authors declare that they have no competing interests.
Funding
None.
Authors’ contributions
YI participated in the surgery, conceived, and conducted the study, and performed the literature search. YI, YT, and HU participated in the surgery. NM and HU supervised manuscript preparation and critically revised the manuscript. All the authors have read and approved the final manuscript.
Acknowledgments
We would like to thank Editage (www.editage.jp) for English language editing.
Table 1 is available in the Supplementary Files section