Emergency Airway Management in a Patient With Tracheoesophageal Fistula and Prior Laryngectomy

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.