Teaching Case

A boy was referred to our institution for head trauma with loss of consciousness. A slight change of the tracheal tube position, placed by the rescue team, induced cervico-thoracic emphysema as well as ventilation problems. The chest CT- scan revealed a tracheal disruption.

A 12 year-old boy fell and underwent a head trauma with loss of consciousness. An oro-tracheal tube was placed. Then, the child was transferred to our hospital. Initially, the artificial ventilation was effective. A chest radiograph showed that the tip of the tube was located too distally. The tube was gently withdrawn. After a short while, cervico-thoracic emphysema appeared. A new chest radiograph confirmed the emphysema and showed a major left pneumothorax and a pneumomediastinum. After evacuating the pneumothorax, further investigations were done to search a tracheal rupture. The chest MDCT- scanner (Fig. 1) showed that the trachea had ruptured in its distal third, between the cartilaginous and the membranous part . A tracheobronchoscopy confirmed the laceration which could be consistent with an intubation accident. The condition of the patient stabilized, then a medical treatment was decided ( intravenous antibiotherapy ,oral intubation without inflated cuff). Five days later, fever was noticed as well as an increase of the white blood cell count. A new chest MDCT-scanner (Fig. 2) was performed which showed a decrease in size of the tracheal tear but development of an abscess next to it. Clinical tolerance was good, so the medical treatment was continued with a broad spectrum antibiotherapy. A tracheobronchoscopy performed at day 12 showed complete recovery of the laceration.Follow up of the mediastinitis was ensured by CT-scanner and mediastinum US (Fig. 3). The last MDCT-scanner was performed two months after the accident to confirm complete healing of the mediastinitis.

Tracheal tears remain relatively rare in children. They are the consequence of either tracheal tube or direct injury (1). The main symptoms are emphysema and pneumomediastinum (1,2) and the usual means to diagnose a tracheal injury is the association of chest radiograph and tracheobronchoscopy (1-3). CT-scanner is the best technique to detect pulmonary or mediastinal complication. In most cases, symptoms appear after the beginning of artificial ventilation (1), often after the tracheal tube is moved. A study (1) revealed that in most cases of iatrogenic tracheal rupture, the laceration located in between the membranous and cartilaginous parts and that its mean length was 4.8 cm. Tracheal rupture almost never involves the proximal third of trachea. Early surgical treatment is usually preferred (1) but the interest for a non surgical treatment is growing. Based on literature data, conservative treatment can be proposed for up to 4 cm lacerations in patients in stable conditions. Such a conservative treatment associating IV antibiotherapy and parenteral nutrition (NPO) has been proposed as early as 1965 by Mengoli and Klassen, cited by Goudy et al (2). Lastly, surgical treatment, such as trachea resection or reconstruction, can be performed in chronic lesions of the trachea. Such repair is technically much more difficult in acute injuries. CT scanner and tracheal endoscopy remain the best diagnostic tools for tracheal disruption and mediastinal abscess. The isotropic imaging provided by new generation multidetectors CT scan is particularly interesting due to its excellent 2D and 3D reconstruction capabilities. Ultrasound should also be mentioned in this context as it can provide effective follow up of an abscess without ionising radiation.