Tracheal granuloma after thyroidectomy with difficult intubation

Tracheal complications after endotracheal intubation or tracheostomy include tracheal stenosis, ulcers, granulomas and tracheomalacia [1]. Of these, tracheal granuloma is a rare complication, and common on the anterior wall of the subglottis [2]. We experienced a case in which a patient with symptoms of airway obstruction due to tracheal granuloma after total thy roidectomy underwent resection of a tracheal granuloma and anastomosis under general anesthesia after bronchoscopy. A 55-year-old male patient had undergone total thyroid ectomy due to thyroid cancer. However, symptoms of upper respiratory infection, cough and sputum, continued after discharge. After 4 months, stridor and dyspnea developed, and flexible bronchoscopy was performed to assess. A granuloma about 1 cm × 1 cm in size was found 3 cm below the vocal cords on fiberoptic bronchoscopy. The patient was transferred to our hospital for diagnosis and treatment using interventional rigid bronchoscopy. According to the history of the first operation, the patient was 166 cm tall and, weighed 73 kg, with a body mass index of 26, classified as, mildly overweight. He had had predictive signs of difficult intubation: short neck, Mallampati class III, thyromental distance of 2 fingerbreadths. He had not had any respiratory symptoms. A 1.5 cm × 1.0 cm-sized thyroid cancer was founded, but no abnormal findings at any other sites were noted on neck computed tomography (CT) scan. On laryngoscopy, the patient’s airway was classified as CormackLehane grade IIIa. His trachea was intubated using an ID 6.5 mm endotracheal tube with stylet after trials with an ID 8.0 mm reinforced an endotracheal tube and an ID 7.0 mm plain endotracheal tube with inserted stylet. The cuff volume was about 5 cc. Anesthesia was adequately maintained with N2O-O 2sevoflurane at bispectral index 44 -58 during the thyroidectomy. The surgeon placed a 10 cm high pillow under the shoulder and extended the neck simultaneously for the thyroid surgery. The operating time for the thyroidectomy was 84 minutes. In our hospital, CT scan revealed a polypoid mass about 1 cm in length with erosion of cartilage in the right lateral aspect of the upper trachea, along with tracheal stenosis (Fig. 1A). To facilitate the performance of rigid bronchoscopy, propofol and remifentanil were used with rocuronium as anesthetic agents. However, the rigid bronchoscopy could not be performed because the patient had a short neck and limited neck extension. Therefore, the tracheal granuloma was inspected by flexible bronchoscopy instead of rigid bronchoscopy (Fig. 1B), and the trachea was intubated by guided flexible bronchoscopy using an ID 6.5 mm endotracheal tube. The decision was made to perform surgery on the patient in the Department of Thoracic Surgery on the following day. During the second operation, the tracheal region including the granuloma was resected and the trachea was anastomosed under general anesthesia using N2O-O 2-sevoflurane. A 1.0 cm × 1.0 cm-sized granuloma was located on the lower cricoid car tilage and stenotic change was observed around the granuloma. As a result of this tissue biopsy, the mass was diagnosed as a typical granuloma with ulcer and sclerosis. Because this patient had undergone thyroidectomy due to thyroid cancer, we assumed that a mass in the trachea might be caused by extended cancer. However, the mass was located at the region of the tube-tip and had a yellowish and smooth sur