Title : Anunexpected cause of difficult intubation: Tracheobronchopathia osteochondroplastica - A case report
Abstract:
Tracheobronchopathia osteochondroplastica(TPO) is characterized by multiple osseous and cartilaginous nodule in the submucosa of the trachea and main bronchi. The clinical manifestations are variable, from no symptom to cough, hemoptysis, dyspnea. There is no specific treatment until now. Fortunately it is slowly progressive. But it can be fatal if accompany with other respiratory complications. Here we would like to share our experience because TPO is one of the unexpected difficult intubation. In this aspect it is important for anesthesiologists to be aware of TPO. A 17-year-old female was scheduled for appendectomy. Endotracheal intubation was attempted using a video laryngoscope. Intubation was attempted using an armored ETT of internal diameter 6.5 mm. We could see the vocal cords easily. But by the time two-thirds of the cuff of the ETT passed the vocal cords, it was no longer advanced into the trachea. After that, we tried again with an ETT of internal diameter 6.0 mm. When the cuff of the tube entered the vocal cords, we felt some resistance where we failed to advance the ETTs in the previous attempts. But finally the intubation was successful. We reexamined the cervical CT and chest x-ray of patient during surgery. The cervical CT showed a number of nodular calcifications that protrude into the tracheal lumen and osseous ridges in the trachea. TPO was first described as 'ossific deposits on the larynx, trachea, and bronchi' by Wilks in 1857, and Secrest et al. named the disease 'Tracheobronchopathia osteoplastica' in 1964. CT can show the protrusion of calcified cartiliginous nodules into the anterior and lateral lumen of tracheal wall. With the fiberoptic bronchoscopy, considered as a gold standard for the diagnosis of the TPO, bony or cartilaginous nodules on tracheal wall can be confirmed. In the event of unexpected difficult intubation, anesthesiologists should considered the possibility of TPO and other means of airway maintenance, such as supraglottic airways, if intubation is failed with endotracheal tubes of smaller internal diameter.
