3Shahbaz Ghazi,1,2Ahmed Albaqshi
1King Fahd University Hospital, 2King Fahd Hospital-Al-Hofuf, 3National Guard Hospital, Riyadh,
Tracheomalacia refers to diffuse or segmental tracheal weakness. Most commonly, tracheomalacia develops after prolonged endotracheal intubation or tracheostomy. Therapy is warranted in symptomatic patients with severe tracheomalacia. Relief of airway obstruction via stenting often provides immediate improvement of both airflow and symptoms. However, stent placement is associated with significant complications.
Material(s) and Method(s):
We present the case of a 71-year-old man who was brought to the emergency department with acute respiratory distress. The patient was known to have tracheomalacia with tracheoesophageal fistula. He had multiple medical comorbidities, including longstanding hypertension, diabetes mellitus, and asthma. The patient had progressive decline in the level of consciousness and was admitted to the intensive care unit for further management. Despite the maximum ventilatory support, the patient did not achieve adequate oxygenation level. The patient underwent tracheal stent placement by the interventional radiology team. The insertion was unsuccessful despite three attempts. The tracheal stent had migrated into the upper esophagus on the first and second insertion attempts (Image 1 a,b,c,d and Image 2 a,b,c) . Since the patient was unstable to tolerate further attempts, the multidisciplinary team recommended the insertion of an esophageal stent to cover the tracheoesophageal fistula (Image 3 a,b). Despite this, the patient continued to have air leakage with progressive worsening of his respiratory condition as he developed multiorgan failure and died.
The management of tracheomalacia in the setting of tracheoesophageal fistula may pose several challenges. The present case highlighted an essential complication of stent placement with having the stent migrated into the tracheoesophageal fistula, which is an unusual site of migration. Multidisciplinary approach is crucial in the management of difficult cases of tracheomalacia.