1. PATIENT PRESENTATION
An approximately 70‐year‐old female with a history of anaplastic thyroid cancer with metastasis to the lungs and cervical spine presented to the emergency department with a new fluctuant neck swelling of approximately 1 week's duration (Figure 1, Video 1). The mass was non‐tender but oscillated paradoxically with respirations. The patient also noted a mildly hoarse voice. One month previously, she underwent total radical thyroidectomy with extensive soft tissue resection, including cricotracheal resection with primary re‐anastomosis. The patient underwent computed tomography with contrast of the neck. (Figure 2).
FIGURE 1.
Anterior view of neck.
VIDEO 1.
Video of the left neck showing paradoxical inflation with expiration and deflation with inspiration.
FIGURE 2.
Axial, coronal and sagittal computed tomography of neck with intravenous contrast demonstrating focal defect in the left anterior trachea with surrounding 7 × 6 cm air‐filled cavity.
2. DIAGNOSIS
2.1. Postoperative tracheal dehiscence
The computed tomography revealed a large, predominantly air‐filled collection in the anterior neck measuring 7 × 6 × 6 cm and communicating with a contained tracheal perforation. The patient was taken to the operating room the following day, confirming breakdown of the cricotracheal repair. The patient underwent debridement and revision tracheostomy.
Tracheal dehiscence is the complete disruption of the tracheal wall. This is in contrast to tracheal diverticulum, which represents an outpouching of the tracheal wall. 1 , 2 Anastomotic dehiscence occurs in 2.5%–11% of postoperative patients. 3 , 4 Known risk factors for dehiscence include diabetes and laryngotracheal resections, as well as long resections, pediatric age group, preoperative tracheostomy, and tension on the anastomosis. The current case is unusual in the timing of the diagnosis (1 month after surgery) and the large size of the perforation. 5 , 6 Surgical complications of tracheal repair may occur in up to 27% of patients. Bilateral recurrent nerve palsy is the most common complication. Other potential complications include anastomotic dehiscence, hypoparathyroidism, glottic edema, anastomotic stenosis, bleeding, respiratory insufficiency, and ventilator dependency. 7 , 8
Tourkow B, Wang HE. Patient with neck swelling. JACEP Open. 2023;4:e12942. 10.1002/emp2.12942
Funding and support: By JACEP Open policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Dr. Wang is Editor in Chief of JACEP Open but had no role in the editorial decision making process for this article.
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