2025 FSA Podium and Poster Abstracts

Introduction: Tracheal stenosis is a recognized complication following tracheostomy, particularly in patients requiring prolonged mechanical ventilation or multiple airway interventions. Managing recurrent tracheal stenosis presents significant anesthetic challenges, including difficult airway management, risk of failed ventilation, and potential airway compromise. We present the case of a 27-year-old female who developed recurrent tracheal stenosis following a tracheostomy after a motor vehicle collision (MVC), highlighting the difficulties encountered and the eventual need for repeat tracheostomy.

Methods: The patient, initially tracheostomized after an MVC, was successfully decannulated but later developed symptomatic tracheal stenosis requiring resection of the second and third tracheal rings. She later presented to our facility with audible stridor, indicative of re-stenosis. Tracheal dilation under monitored anesthesia care (MAC) with local anesthesia was attempted. However, the patient developed laryngospasm, necessitating endotracheal intubation. Multiple attempts were made to secure the airway using different-sized endotracheal tubes (ETT) with video laryngoscopy and fiberoptic scope. Despite optimal visualization, the ETT could only be partially advanced, with the tip and proximal balloon passing through the stenotic segment but failing to progress further. Upon inflation, the ETT balloon was positioned at the vocal cords, preventing effective ventilation. The surgical team attempted tracheal dilation over the ETT but could not pass a bronchoscope with a dilator due to tube size. Despite these challenges, the patient remained hemodynamically stable and adequately ventilated. Given the inability to secure a definitive airway, a tracheostomy was performed.

Results: The tracheostomy successfully restored a secure airway and relieved the patient’s respiratory distress. Postoperatively, the patient was closely monitored for airway patency, with further interventions planned for her recurrent stenosis. This case highlights the limitations of tracheal dilation in severe stenosis and the necessity of a contingency plan for high-risk patients.

Discussion: Recurrent tracheal stenosis presents significant anesthetic challenges, particularly in securing airway patency and managing failed intubation. This case illustrates the risks of sedation in patients with upper airway pathology, where even minor stimulation can precipitate obstruction. Despite optimal visualization, the inability to advance an ETT past the stenotic segment underscores the limitations of conventional intubation in patients with fixed, fibrotic lesions. Difficult airway management guidelines emphasize a stepwise approach, integrating non-invasive and invasive techniques. While fiberoptic intubation is preferred in tracheal stenosis, success depends on luminal diameter, with <5 mm significantly increasing failure risk. Spontaneous ventilation is often prioritized to prevent airway collapse, though smaller tubes or supraglottic devices may have limited utility in subglottic pathology. Given the failure of non-surgical approaches, timely recognition of the need for a surgical airway was critical, reinforcing the ASA Difficult Airway Algorithm’s recommendation for early escalation in high-risk cases. This case highlights the importance of interdisciplinary collaboration in managing complex airway pathology. It also underscores the need for improved techniques in tracheal stenosis management, such as refined dilation methods and novel stenting approaches, to optimize patient outcomes.