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A Case Report of an Inadvertent Placement of Tracheostomy Tube Into the Pharynx After Emergency Tracheostomy

Management of a Failed Surgical Airway

Awad, Motaz, MD; Yaghoubian, Saman, DO

doi: 10.1213/XAA.0000000000000930
Case Reports

Inadvertent placement of a tracheostomy tube through the stoma with the distal tip cephalad in the pharynx is an unusual but potentially devastating complication. Previously reported only once in the literature, its occurrence is not well known. There are several causes of ineffective ventilation after an emergency surgical airway, and an incorrectly placed tracheostomy tube is a differential diagnosis to consider. Prompt identification of this rare complication is essential because the consequences can be fatal. We present a case describing the inadvertent insertion of a tracheostomy tube into the pharynx during emergency tracheostomy and its subsequent management.

From the Department of Anesthesiology, New York Medical College, Westchester Medical Center, Valhalla, New York.

Accepted for publication October 11, 2018.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Motaz Awad, MD, Department of Anesthesiology, Westchester Medical Center, 100 Woods Rd, Macy Pavilion, Room 2391, Valhalla, NY 10595. Address e-mail to

© 2019 International Anesthesia Research Society
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