Introduction: Laryngeal carcinoma is often treated with radiotherapy and/or chemo-radiotherapy, however laryngectomy is still frequently used in patients with persistent and recurrent disease. Pharyngocutaneous fistula, a serious complication of laryngectomy, poses significant morbidity and mortality risk. A retrospective study in the UK showed that overall incidence of fistula following laryngectomy to be 29.2%. These patients often have challenging airways post fistula formation. In 2020, one case report showed a successful fiberoptic intubation technique through a laryngopharyngo-cutaneous fistula. However, no literature discusses the complications from pharyngocutaneous fistula intubation.
Description: A 40-year-old male with past medical history of oral squamous cell carcinoma presented as outside hospital transfer for left neck bleeding. Patient had a complicated surgical history including left composite mandibular resection and neck dissections with flap reconstruction in 2017. He subsequently developed wound breakdown necessitating multiple I&D leading to eventual tracheostomy with debulking of pectoral flap, which ultimately failed and was removed. Upon arrival, pt had continuous bleed via left neck defect. Given the patient’s multiple tracheostomies and extensive local malignant involvement, the decision was made to intubate him via lateral neck defect. The fiberoptic scope was used to visualize the glottis through the pharyngeal opening. The scope was advanced beyond the glottis and an endotrachel tube was placed. . Neurosurgery was able to coil embolize the right lingual artery. The patient had increasing pressor requirements both intra and post operatively, decompensating further on arrival to MICU when he eventually lost a pulse. Bilateral large tension pneumothoraces were identified during code, necessitating bilateral chest tube placement. ROSC was achieved post chest tube placement but there was concern for tracheal injury given tension pneumothoraces.
Discussion: This clinical scenario demonstrated tracheal injury s a possible complication from pharyngocutaneous fistula intubation, even with fiberoptic method. Given the patient population already had radiation and surgical complication in the region, pharyngocutaneous fistula intubation should be proceed with extreme caution.
