Maik Jonathan, Kwon Ochan, Greenberg Menachem, Bandagi Aamir, Chuang Michael
Department of Emergency Medicine, SBH Health System, Bronx, New York.
Department of Emergency Medicine, SBH Health System, Bronx, New York.
J Emerg Med. 2025 Oct;77:38-41. doi: 10.1016/j.jemermed.2025.07.019. Epub 2025 Jul 11.
Airway management of the patient with a history of total laryngectomy is complicated by iatrogenic changes to the patient's upper airway. Securing the airway through the pharynx is impossible because of surgical closure, and front-of-neck surgical airway is not feasible due to the existing tracheostomy. The only viable option is via the existing tracheal stoma. Further complicating this scenario, patients who have had an insertion of a tracheoesophageal prosthesis (TEP), inherently have an iatrogenic tracheoesophageal fistula (TEF). We present a case of airway management in a patient status post laryngectomy and insertion of a TEP.
A 64-year-old male with a history of laryngectomy and subsequent insertion of a TEP presented with acute hypoxic respiratory failure to an emergency department (ED) without immediate otolaryngology backup available. The management included fiberoptic intubation through the stoma. Being unaware of the TEF inherent to patients with TEP, the patient was intubated via flexible fiberoptic scope through the tracheal stoma. The intubation was recognized as esophageal, and the patient was then successfully re-intubated through the stoma using the carina as a visual, confirmatory landmark. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be familiar with the management of patients with a TEP. In addition to the limitations to airway management imposed by the laryngectomy and tracheostomy, the iatrogenic tracheoesophageal fistula further complicates airway management. Flexible fiberoptic laryngoscopy through the tracheal stoma should be performed with the goal of visualizing the carina to confirm endotracheal placement. Multiple adjunct airway devices may be helpful in managing the airway of these patients.
全喉切除术患者的气道管理因上呼吸道的医源性改变而变得复杂。由于手术封闭，经咽部确保气道安全是不可能的，且由于已有气管造口术，颈部前方手术气道也不可行。唯一可行的选择是通过现有的气管造口。使这种情况更加复杂的是，植入了气管食管假体（TEP）的患者固有医源性气管食管瘘（TEF）。我们报告一例喉切除术后并植入TEP患者的气道管理病例。
一名64岁男性，有喉切除术及随后植入TEP的病史，因急性缺氧性呼吸衰竭被送至急诊科，当时没有耳鼻喉科的即时支援。处理措施包括经造口进行纤维支气管镜插管。由于未意识到TEP患者存在固有TEF，该患者通过可弯曲纤维支气管镜经气管造口进行插管。插管时被识别为插入了食管，随后以隆突作为可视确认标志，通过造口成功为患者重新插管。
急诊医生为何应了解此事？：急诊医生应熟悉TEP患者的处理。除了喉切除术和气管造口术给气道管理带来的限制外，医源性气管食管瘘使气道管理更加复杂。经气管造口进行可弯曲纤维喉镜检查应以看到隆突以确认气管内插管位置为目的。多种辅助气道装置可能有助于管理这些患者的气道。
