Intraoperatively Diagnosed Tracheal Tear after Using an NIM EMG ETT with Previously Undiagnosed Tracheomalacia

Tracheal rupture is a rare complication of endotracheal intubation. We present a case of tracheal rupture that was diagnosed intraoperatively after the use of an NIM EMG endotracheal tube. A 66-year-old female with a recurrent multinodular goiter was scheduled for total thyroidectomy. Induction of anesthesia was uncomplicated. Intubation was atraumatic using a 6？mm NIM EMG endotracheal tube (ETT). Approximately 90 minutes into the surgery, a tracheal tear was suspected. After confirming the diagnosis, conservative treatment with antibiotic coverage was favored. The patient made a full recovery with no complications. Diagnosis of the tracheal tear was made intraoperatively, prompting early management. 1. Introduction Tracheal rupture is a rare iatrogenic complication, most commonly due to blunt trauma outside the hospital setting. It is occasionally a complication of surgical manipulation of the trachea. It can also complicate orotracheal intubation due to the tip of endotracheal tube (ETT) getting caught in the fold of posterior trachea during insertion. Diagnosis usually waits until after extubation based on clinical suspicion and confirmed by bronchoscopy. If not properly managed, severe respiratory distress and even death may result. We present a case of tracheal rupture that was diagnosed intraoperatively via bronchoscopy and managed conservatively. 2. Case Presentation A 66-year-old female with a history of a subtotal thyroidectomy 20 years ago was scheduled for a total thyroidectomy due to a recurrent symptomatic multinodular goiter. She presented with increasing dysphagia, dyspnea, and a nontender neck mass. Preoperative fine-needle aspiration showed benign follicular hyperplasia. CT scan revealed an enlarged thyroid nodule on the left lobe measuring 4.7 × 3.1？cm with deviation of the trachea to the right (Figure 1). Other significant medical history included diabetes, hypertension, and hyperlipidemia. Figure 1: Preoperative CT scan showing deviation and compression of trachea. After induction of anesthesia with propofol and succinylcholine, a 6？mm Medtronic nerve integrity monitor (NIM) EMG ETT was inserted over a stylet for an uneventful intubation. Approximately 90 minutes into the surgery, a gurgling noise was perceived from the operative site. This was followed by an increase in inspiratory peak pressure and desaturation to 85%. Tube placement was confirmed by laryngoscopy, and the cuff was further inflated with 2？mL of air to minimize leaks. Fiber optic bronchoscopy revealed blood around the ETT, which was suctioned resulting in improved