Subcutaneous Emphysema Following Tracheocutaneous Fistula Closure in a Pediatric Patient: A Case Report

Tracheocutaneous fistula (TCF) is a known complication following tracheostomy decannulation. While closure is generally safe, rare but potentially life-threatening complications such as subcutaneous emphysema may occur. We report the case of a four-year-old boy with a history of prematurity, cleft palate, cleft lip, and ectopic kidney, who developed persistent TCF after tracheostomy performed for aspiration pneumonia at two months of age. Following decannulation and subsequent scheduling for elective closure, the patient underwent primary surgical repair under general anesthesia. Ten hours postoperatively, he developed diffuse subcutaneous emphysema with respiratory distress. Emergency intervention included reopening of the wound, intubation, drain placement, and re-suturing, followed by intensive care monitoring. Imaging confirmed extensive subcutaneous emphysema and a small pneumothorax. Supportive management with mechanical ventilation, nasogastric feeding, intravenous fluids, and antibiotics led to gradual resolution. He was discharged in stable condition after six days and has remained well on follow-up. Postoperative ventilation was essential to maintain airway stability despite the potential risk of propagation. There is a need for individualized perioperative planning and vigilant monitoring in pediatric patients. TCF closure is generally safe, but clinicians should remain alert to potential airway complications such as subcutaneous emphysema. Early recognition and prompt management are critical for favorable outcomes. This case emphasizes the importance of careful perioperative decision-making, especially in children with multiple comorbidities.