Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.

The patient is a 53-year-old white female who was in a serious rollover motor vehicle accident in December 1996. She sustained a femur fracture, intracranial hemorrhage, bilateral upper extremity fractures, a right pneumothorax, and multiple rib fractures. The patient was life-flighted to Herman Hospital with a grim prognosis. One week into her hospitalization she underwent percutaneous tracheotomy for permanent airway access. She then developed ARDS and was ventilator-dependent for 3 months. The patient required hospitalization for 4 months and was eventually weaned from the ventilator and had her tracheostomy tube downsized and then decannulated. However, 5 weeks later, she developed airway obstruction and necessitated emergent open tracheotomy. The patient current has a metal tracheostomy tube in place and presents for further evaluation of her airway obstruction.

The patient denied any hemoptysis or dysphagia. She describes frequent dyspnea even with her tracheostomy in place and persistent cough. Her current medications include pepcid, Glucophage, Cardura, and NPH insulin. She had a 40 pack-year smoking history. On physical exam, the patient was afebrile, with mildly elevated blood pressure. Pertinent findings included multiple well-healed facial scars. Her tracheotomy site was clean, with a metal tracheotomy tube in place. Her laryngeal landmarks were palpable, and her neck was thin. Auscultation of her lungs revealed scattered rhonchi. Cardiac exam was normal and there was no peripheral edema. Neurologic exam was grossly intact. Her laboratory values were within normal limits. CXR showed bilateral basilar atelectasis with no obvious infiltrate. The tracheostomy tube was midline. There was no pneumothorax or subcutaneous air.

The patient was taken to the operating room and underwent suspension laryngoscopy and rigid bronchoscopy. The larynx was slightly rotated posteriorly and to the left with some asymmetry. In the immediate subglottic region, patient had a firm, concentric narrowing of the trachea to approximately 5 mm in diameter in greatest dimension. As the scope passed through this region, it appeared the trachea distal to the stenosis was offset to the right, requiring angling of the scope to pass this region. The tracheostomy tube could be seen off on the right. When the tracheostomy tube was subsequently removed, soft collapse of the anterior tracheal wall was noted consistent with tracheomalacia. When the scope was passed more distally, the tracheal rings appeared more normal with structural integrity and open passage. The patient underwent YAG laser vaporization of her subglottic stenosis without complications. She is currently doing well and is followed in outpatient clinics. Her metal tracheostomy tube is still in place.

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