Emergency presentation of iatrogenic airway stenosis followi
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A 59-year-old man presented to the emergency department with recent-onset biphasic stridor, dyspnoea and increased work of breathing on the background of prolonged intubation for the novel COVID-19 2?months previously. Flexible laryngoscopy revealed bilateral vocal fold immobility with a soft tissue mass in the inter arytenoid region. The patient’s symptoms improved with oxygen therapy, nebulised epinephrine (5?mL; 1:10 000), and intravenous dexamethasone (3.3?mg). The following morning, the patient was taken to theatre, underwent suspension microlaryngoscopy and found to have a bilateral fixation of the cricoarytenoid joints and a large granuloma in the interarytenoid area. He underwent cold steel resection of the granuloma and balloon dilatation between the arytenoids, with the hope of mobilizing the joints. This failed and CO2 laser arytenoidectomy was performed on the left side. The stridor had resolved postoperatively, with normalization of work of breathing and the patient was discharged home on the first postoperative day.

Patients requiring mechanical ventilation for COVID-19 suffered prolonged endotracheal intubation due to the need for high ventilation pressures, nursing in the prone position (higher risk of decannulation) and high viral concentration in the upper aerodigestive tract leading to possible infection of healthcare providers during and after tracheostomy insertion.

Common symptoms of laryngotracheal stenosis include dry cough, hoarseness, swallowing dysfunction, and at a more advanced stage, stridor. Early diagnosis and treatment of these cases have been shown to yield superior therapeutic outcomes7 and prevent long-term sequelae. A study of 62 patients from our institution showed that endoscopic surgery can be an effective strategy for definitively treating postintubation tracheal stenosis in most patients.8 Rigid bronchoscopic intervention is a cogent alternative in cases of subglottic and tracheal stenoses,9 though would be unsuitable for glottic pathology as in this case. Suspension laryngoscopy allowed CO2 laser arytenoidectomy, which created a patent airway in the posterior third of the glottis thus avoiding a tracheostomy.

Patients with long-term airway stenosis are often misdiagnosed with respiratory conditions such as asthma and thus suffer delays in initiation of diagnostic and therapeutic interventions. It is important to promote a high index of suspicion among general practitioners, emergency medicine, and respiratory physicians in order to facilitate early diagnosis and maximize patient outcomes.

Source:https://casereports.bmj.com/content/13/12/e238508
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