Tracheal ring fracture as a consequence of external laryngeal manipulation during endotracheal intubation

We report a case of tracheal ring fracture after external laryngeal manipulation for assisting intubation because of difficult laryngoscopy during induction of anesthesia. The patient was a 64-year-old female suffering from a large multinodular goiter scheduled to undergo general anesthesia with endotracheal intubation for thyroidectomy. Laryngoscopy was performed, which did not visualize the glottis. With application of forceful external laryngeal manipulation, intubation was successfully achieved on the third attempt. But on skin incision and tissue exposure, a single fractured site on the second tracheal ring was noted. Fiberoptic bronchoscopy was performed and showed the tracheal mucosa remaining unmolested without endotracheal lesion or cartilage dislodgement into the trachea. The operation was carried out uneventfully and the fracture was treated conservatively. After extubation, the patient recovered smoothly and had no symptoms suggestive of tracheal narrowing or hoarseness of voice. Neck computed tomography and fiberoptic bronchoscopy were performed postoperatively, both of which showed normal tracheal ring alignment without evidence of edema or hematoma. The patient was discharged 3 days after operation. At the 3-month follow-up, she displayed good airway function and phonation. After review of her clinical history, we speculated that the tracheal ring fracture was caused by forced external compression of the tracheal cartilage during endotracheal intubation.