A 14-year-old boy presented to the emergency department of a district general hospital in acute respiratory distress with aphonia. He was thrown off his motorcycle when his neck struck a rope. On examination, he was tachypneic and tachycardic with cervical bruising, subcutaneous emphysema, and an abrasion below the angle of mandible. He was intubated after which the cervical subcutaneous emphysema worsened, but he remained hemodynamically stable. A computed tomographic scan revealed complete transection of the trachea below the cricoid with the endotracheal tube lying adjacent to the transected trachea with marked pneumomediastinum. He was subsequently reintubated using fiberoptic guidance directing the endotracheal tube into the distal segment (Fig 2A). Bilateral pneumothoraxes developed, which were drained prior to transfer to the regional cardiothoracic unit. An esophagoscopy revealed a laceration in the anterior wall of the esophagus. A transverse cervical suprasternal incision was made and a tracheostomy tube was secured in place through the transected distal segment. A further transverse incision at the level of the thyroid cartilage was placed to explore the injury, having already secured the airway. Complete transection of the trachea at the level of cricoid and subtotal transection of the esophagus in three-quarters of its circumference was confirmed. The recurrent laryngeal nerves could not be identified. A nasogastric tube was placed. After repairing the oesophageal injury with interrupted 3– 0 Vicryl, a sternocleidomastoid flap was placed anterior to the esophagus. The posterior wall of the trachea was repaired with continuous Vicryl 3– 0, whereas the cartilaginous portion was repaired with interrupted 3– 0 Prolene. The tracheostomy was repositioned through the cephalad incision and a mediastinal drain was placed adjacent to the site of anastomosis. He was then transferred to the intensive care unit. His postoperative course was complicated by acute respiratory distress syndrome from which he made a rapid recovery. He was ventilated until day 5. Postoperative contrast swallow did not show any evidence of an anastamotic leak, and he commenced oral feeding. The remaining period in the hospital was uneventful. He was discharged with his tracheostomy capped off. At week 6, at clinical review, he showed some improvement of speech, but with marked hoarseness. At the 6-month follow-up, there were no signs of recovery of the vocal cords. He underwent a partial cordectomy allowing for the removal of his tracheostomy, with excellent recovery of his voice. He is currently being followed-up on an annual basis.
Posted on: Fri, 26 Dec 2014 22:15:46 +0000
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