A 77-year-old man underwent thoracic surgery. He had a history of two previous operations: parapharyngeal
tumor removal with temporal
tracheotomy 14 years ago and, two years later, a sinus surgery when, according to our
anesthesia registry, intubation was extremely difficult due to
stricture of the trachea underneath the
tracheotomy scar. Pathology was not fully elucidated. Preoperative examinations including chest x-ray, spirogram and CT were not remarkable. The
scar above the suprasternal notch was visibly sunken and retracted with respiration.
Stridor was auscultated but breathing was not labored. The patient was anesthetized with
propofol and intubation was smooth. During surgery
anesthesia was maintained with
sevoflurane,
remifentanil and
rocuronium. However, extubation was followed by desperate gasping and severe respiratory distress. The
tracheotomy scar caved in and the airway collapsed. Continuous airway pressure via a facemask restored airway patency and improved breathing. After overnight respiratory support with non-invasive
positive pressure ventilation (NPPV), patient was weaned from
ventilator. Airway collapse and the two episodes of
respiratory failures while under
general anesthesia were attributed to post-
tracheotomy tracheomalacia.