A 56-year-old woman with a history of well-controlled hypertension on losartan and idiopathic subglottic stenosis compromising her airway by 75% presented to our institution for an outpatient direct microlaryngoscopy, CO2 laser of stenosis, tracheal dilation, and injection of steroid and mitomycin C. The patient previously had excellent functional capacity and was a marathon runner, however as her stenosis progressed she presented with hoarseness and dyspnea on exertion. She was able to tolerate lying supine. Her history, physical exam, labs, and vitals were otherwise unremarkable.
The patient was premedicated with midazolam and brought to the OR. General anesthesia was induced with propofol, lidocaine and succinylcholine. Mask ventilation was easy. The patient was turned 180 degrees and the airway handed off to ENT who inserted an Ossoff Karlan laryngoscope with jet ventilation cannula. Maintenance of anesthesia was with propofol and remifentanyl infusion. Per ENT request the patient was given muscle relaxation with 4mg cisatracurium to assist with Ossoff Karlan laryngoscope placement and visualization. The case proceeded as planned with intermittent jet ventilation titrated to chest rise. At the conclusion of the case, the Ossoff Karlan laryngoscope was removed and anesthetic infusions titrated down. Mask ventilation was performed and when train of four demonstrated 0 twitches the decision was made to place an LMA while the patient regained muscle strength. The patient's strength gradually improved, muscle relaxation was reversed and she emerged from anesthesia. The LMA was removed without complication. Upon transfer to the gurney, the patient coughed. She continued to cough and became dyspneic, complaining of difficulty breathing and progressively worsening chest pain. A chest xray was ordered and ENT notified. Over the course of 5 minutes post-extubation the patient was noted to have swelling around the bilateral eyes, midface, anterior and lateral neck, and anterior chest with crepitus. Her condition worsened and the decision was made to reintubate the patient. Chest xray demonstrated massive subcutaneous emphysema. ENT performed an additional direct laryngoscopy and the patient was found to have an anterior cricoid cartilage fracture. The patient was transferred to the ICU intubated and returned to the OR on POD#2 for anterior cricoid fracture repair and evacuation of subcutaneous emphysema. The patient was discharged on POD#3 and the following month ran a half marathon.
Discussion:
1) Subcutaneous emphysema
2) Jet ventilation
3) Cricoid cartilage fracture, tracheal stenosis lasering, balloon dilation
