UNASSIGNED: Tracheal injury is a rare but potentially serious acute complication of endotracheal intubation. Very few cases of tracheal injury associated with coagulation abnormalities have been reported in the literature. We present a rare case of a patient presenting with tracheal injury in combination with coagulation abnormalities following thyroidectomy.
UNASSIGNED: A 58-year-old woman with a history of postoperative chemotherapy for breast cancer, gastric polyps, multiple colonic polyps, esophageal papillary adenomas, and thyroid adenomas presented with dyspnea following 10 ml hemoptysis on the third day after thyroidectomy; she was admitted to the intensive care unit and underwent tracheal intubation for maintaining the airway. Subsequent bronchoscopy revealed a nodular red neoplasm 5-cm from the carina in the trachea obstructing part of the lumen, with a small amount of fresh hemorrhage on the surface. Tracheal injury was considered the preliminary diagnosis. Fiberoptic bronchoscope guided tracheal intubation helped prevent rupture of the tumor, and the cannula was properly inflated to arrest the bleeding while blocking the lower part of the trachea. An emergency surgical evacuation of the cervical hematoma was performed for managing postoperative bleeding. The patient demonstrated persistent pancytopenia despite frequent transfusions. Laboratory examination results revealed abnormal coagulation parameters, anemia, and hepatic dysfunction. Following a multidisciplinary team discussion, pituitrin for hemostasis, tranexamic acid for strengthening hemostasis treatment, and nutritional support and anti-infection treatment were initiated. Endotracheal tube cuff inflation was performed to compress the bleeding site. Complete resolution of the subcutaneous hematoma was observed nine days after the tracheal injury; bronchoscopy revealed residual ecchymosis in the airway hematoma with no evidence of obstruction.
UNASSIGNED: Conservative management of tracheal injury limited to the mucosa or submucosa without significant amount of active bleeding using endotracheal intubation is considered a practical and effective approach. Successful management was ensured by appropriate clinical suspicion, early multidisciplinary team discussion, and prompt diagnosis and interventions.

BACKGROUND: Mediastinoscopic surgery for esophageal cancer facilitates early postoperative recovery. However, it can occasionally cause serious complications. Here, we present the case of a patient with a tracheal injury diagnosed by a sudden increase in end-tidal carbon dioxide (EtCO2) during mediastinoscopic subtotal esophagectomy.
METHODS: A 52-year-old man diagnosed with esophageal cancer was scheduled to undergo mediastinoscopic subtotal esophagectomy. During the mediastinoscopic procedure, the EtCO2 level suddenly increased above 200 mmHg, and the blood pressure dropped below 80 mmHg. We immediately asked the operator to stop insufflation and found a tracheal injury on the right side of the trachea near the carina by bronchoscopy. The endotracheal tube was replaced with a double-lumen tube, and the trachea was repaired via right thoracotomy. There were no further intraoperative complications. After surgery, the patient was extubated and admitted to the intensive care unit.
CONCLUSIONS: Monitoring EtCO2 levels and close communication with the operator is important for safely managing sudden tracheal injury during mediastinoscopic esophagectomy.

Robotic thyroidectomy is one of the most advanced surgical procedures used to manage benign and malignant thyroid nodules. However, complication risks such as tracheal injury still exists. Tracheal injury in robotic thyroidectomy is difficult to detect and is one of the life-threatening complications. This study reviews the current literature on the tracheal injury following robotic thyroidectomy and also discusses our findings on 2060 cases of robotic thyroidectomy via Da Vinci Surgical System performed in our department and finally presents 3 cases treated in our center. PubMed and Web of Science database were searched using Medical Subject Headings (Mesh) related to \"tracheal injury\" and \"robotic thyroidectomy\". The search was conducted without publication date limits. We reviewed the literature and summarized common causes, diagnosis and therapeutic options of tracheal injury in robotic thyroidectomy, which has been described in comparison studies or retrospective studies. Tracheal injury is often diagnosed when patients suffer from dyspnea and usually leads to severe postoperative consequences. Tracheal injury can be suspected in all patients having subcutaneous emphysema, pneumomediastinum, pneumothorax or dyspnea after robotic thyroidectomy. Tracheoscopy is necessary to determine the location and size of tracheal injury. In patients whose condition is stable and the injury is contained, conservative treatment is feasible. Certainly, primary closure or tracheotomy is necessary for patients with serious respiratory difficulty or pneumothorax.

BACKGROUND: Tracheal laceration is very rare but can be life-threatening if proper treatment is not provided. The general concept for the management of tracheal laceration is surgical repair through cervical incision or via thoracotomy. However, in the case of tracheal laceration after tracheostomy, tracheostoma could be extended to avoid urgent surgical repair and additional incision.
METHODS: A 30-year-old Asian woman suffered intracerebral hemorrhage. Tracheostomy was necessary for prolonged ventilator care. While tracheostomy was performed, the posterior tracheal wall was torn. After observing that, we reinserted endotracheal tube through the oral orifice. Following bronchoscopy showed torn posterior tracheal wall. The tearing wound was 5-6 cm in length, from the middle to distal parts of the trachea. We used minimally invasive procedure for extending the already existing tracheostoma.
CONCLUSIONS: In the case of tracheal laceration related to tracheostomy, a new incision is not necessary because the tracheal opening already exists. Using the extended tracheostomy technique, tracheal laceration can be repaired by endotracheal suture method.

Thyroidectomy is a safe procedure that is frequently performed for benign or malignant thyroid disease. Complications after thyroidectomy occur in approximately 3%-5% of patients. Tracheal perforation is a very rare post-thyroidectomy complication, and delayed tracheal perforation without intraoperative tracheal injury is even rarer; only 25 case reports have been published globally, with varied management. We present the case of a 36-year-old man presenting with dyspnea and cough 2 weeks after left thyroidectomy. A defect measuring approximately 2 cm was confirmed on the anterior wall of the trachea by computed tomography and flexible laryngoscopy. The patient\'s symptoms improved with conservative treatment including systemic steroids, and surgical treatment was not required. Even in the absence of unusual intraoperative events, delayed tracheal necrosis and perforation should be considered as possible postoperative complications following thyroidectomy.

BACKGROUND: Iatrogenic tracheal injury is a rare but potentially morbid condition and often poses a diagnostic challenge due to its rarity and the lack of specific clinical findings. Because a delayed diagnosis is associated with a higher mortality, a prompt diagnosis is essential. We report a case of an iatrogenic tracheal injury detected by subpleural emphysema as a rare initial manifestation.
METHODS: A 75-year-old woman was diagnosed with stage IA2 right lung cancer. During the surgery, visceral subpleural emphysema developed along the lung surface up to the interlobar fissure followed by subcutaneous emphysema in the anterior neck. Suspecting a tracheal injury, we aborted the surgery. Fiberoptic bronchoscopy revealed a longitudinal laceration on the membranous part of the distal trachea without esophageal involvement, consistent with a level II injury. Conservative management was chosen and she had a successful recovery.
CONCLUSIONS: Iatrogenic tracheal injury could initially manifest as visceral subpleural emphysema. Once subpleural emphysema is observed during surgery, a prompt diagnostic workup of the tracheal injury should be performed.

Tracheobronchial injury (TBI) associated with penetrating injuries has various clinical symptoms and often requires urgent surgical repair. A tracheal tube and/or placement of a drainage tube combined with multidetector computed tomography (CT) could be used to manage TBI without surgical repair in eligible patients. In this case report, we describe an 86-year-old woman with subcutaneous emphysema and suspected TBI caused by three knife wounds in her neck. After tracheal intubation at a local hospital, she was transferred to our hospital. On admission, she was diagnosed with subcutaneous and mediastinal emphysema due to TBI, as well as bilateral pneumothorax. We adjusted the position of the tracheal tube to a distal location from the TBI, and placed bilateral thoracic drainage tubes by referring to the CT images taken on admission and during the follow-up. The follow-up CT images revealed healing of the TBI. She did not show any worsening of her symptoms and she was successfully extubated on day 10 of her hospital stay. On day 18, she was considered self-reliant and was transferred to her previous hospital. Based on our experience in this case, we believe that ventilation with appropriate sedation, placement of a tracheal tube, and drainage are important conservative therapies for TBI caused by penetrating injuries. CT is also useful for evaluating the status of TBI.

BACKGROUND: Penetrating neck injuries require prompt recognition, diagnosis and management of critical airways. This case demonstrates an emergent situation that a \"medical negligence\" was avoided with the aid of end-tidal carbon dioxide (ETCO2) waveform.
METHODS: We report a case of malposition of the endotracheal tube into the right hemithoracic cavity for cervical knife trauma, resulting in pneumothorax. Tube placement was not confirmed during emergency airway management, and the patient was directly transferred to the emergency operation room. Assisted by ETCO2 and imaging examinations, the anesthetist timely noticed the absence of ETCO2 waveform and resolved this urgent situation before anesthesia induction.
CONCLUSIONS: This case emphasizes the necessity of ETCO2 waveform and/or X-ray confirmation of endotracheal intubation even in emergent situations.

Tracheal perforation is an extremely rare and potentially dangerous complication of a partial thyroidectomy. The current case represents a unique presentation of delayed tracheal perforation following an uncomplicated thyroid isthmusectomy for tissue diagnosis of an aggressive appearing thyroid mass in the setting of high-dose steroid administration and recent intubation and self-extubation. While conservative management of tracheal perforation can sometimes be appropriate, our patient was successfully managed via primary closure and infrahyoid muscle transposition flap to cover a 5 mm right lateral tracheal wall defect. We recommend caution be exercised following thyroid surgery in the setting of intubation and high-dose steroids.

BACKGROUND: Endotracheal intubation is an essential basic skill for emergency physicians. The procedure can cause complications that should be recognized. Awareness and early identification of complications are needed to allow early intervention to optimize outcomes. The risk factors for tracheal perforation during intubation are typically related to the physician skill and experience and to the patient\'s comorbidities, including body habitus and chronic use of certain medications.
METHODS: We report a case of a 45-year-old man with renal transplant on tacrolimus and prednisolone for 16 years. He presented with decreased level of consciousness due to an acute intracranial hemorrhage and was intubated for airway protection. Post intubation, a significant subcutaneous emphysema was noted on the patient\'s neck and chest, which was subsequently determined to be caused by a tracheal perforation. The management of tracheal injury depends on the size and location of the tear, as well as the patient\'s clinical status and comorbidities. In this case, the tracheal perforation was treated conservatively and was successful. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case has been reported to increase awareness about this rare and potentially life-threatening event. The prevention of this rare injury can be difficult but use of a slightly smaller endotracheal tube in a high-risk patient can be of benefit. In addition, early consideration of this complication when there is an acute change in physiologic status will allow for rapid facilitated management.