Cricoid chondronecrosis: a serious complication of prolonged endotracheal intubation

Abstract

Chondronecrosis is a rare life-threatening complication of endotracheal intubation. This case is a patient with a history of severe brain injury, who developed a cricoid chondronecrosis after prolonged intubation. The complication was suspected when decannulation led to upper airway obstruction and was confirmed by laryngoscopy and computed tomography. We discuss the diagnosis of the condition, the causative factors, treatment through a literature review.

Highlights

• Cricoid chondronecrosis rare, life-threatening complication of prolonged intubation.
• Providers should keep this on their differential for patients who present with upper airway dyspnea in the weeks or months after intubation.
• It is a challenging condition which requires multidisciplinary approach.
• Prevention will reduce the incidence and the economic cost of treatment.

Introduction

Chondronecrosis is a rare complication of endotracheal intubation. It is secondary to excessive pressure on the cartilage by the endotracheal tube. The cricoid ring is the most frequently affected cartilage¹. The diagnosis is suspected in patients with upper airway dyspnea and a prior history of intubation. Computed tomography (CT) imaging is an integral part of the workup, it can be particularly helpful when cricoid chondronecrosis is suspected². Endotracheal intubation-related chondronecrosis can be managed with steroids, nebulization, and physiotherapy. Although some patients are managed conservatively, most reported cases require permanent tracheostomy or even total laryngectomy^3,4. We report a case of cricoid chondronecrosis after prolonged intubation in a patient with a history of severe brain injury. This study has been reported in accordance with the SCARE guidelines⁵.

Case report

A 22-year-old-male patient, with no past medical history, suffered a severe brain injury following a road traffic accident 12 months ago. During his 1 month stay in the intensive care unit, the patient was intubated for 10 days after which he underwent an elective tracheostomy. Multiple attempts at decannulation failed due to signs of severe airway obstruction. He was then referred to our ENT Department for further management. Flexible laryngoscopy showed a fixed left vocal fold. A CT scan revealed complete destruction of the cricoid cartilage, with multiple bony fragments and severe stenosis (Figs. 1, 2). Direct laryngoscopy under general anesthesia revealed a circumferential subglottic stenosis, obstructing 75% of the laryngeal lumen which would be consistent with a grade 3 obstruction according to the Cotton-Myer classification. Based on clinical and imaging information, diagnosis of a postintubation cricoid chondronecrosis was made. The patient was prepared for surgery. Under general anesthesia, the patient was placed in a supine position with a shoulder roll to optimize neck extension. A horizontal incision was made at the second tracheal ring followed by a vertical division of strap muscles and the thyroid isthmus in the midline. The trachea was then incised in the midline and stenotic tissues were removed. We placed a Montgomery laryngeal stent to keep a patent lumen, and the wound was closed in a plan per plan fashion. The tube was removed 8 weeks later. The postoperative period was marked by the reappearance of dyspnea which required recannulation of the patient. The patient is still being followed in our outpatient clinic; we did not manage to decannulate him.

Figure 1: (A, B) Flexible laryngoscopy showed paralysis of the left vocal cord.

Figure 2: (A) Axial CT at the level of the cricoid demonstrating a large lesion in the cricoid region with an important stenosis (arrow). (B) Axial CT Bone window at the same level, depicts the chondronecrosis with multiple bony fragments (arrows).

Discussion

Cricoid chondronecrosis is a rare entity that usually complicates prolonged intubation or previous radiation therapy. It is associated with high morbidity and even mortality in some cases^3,4,6.

The underlying mechanism of postintubation chondronecrosis is not fully understood.

It is thought that the 2 main pathophysiological mechanisms are vascular and mechanical. As the internal perichondrial arterioles ensures the majority of blood supply to the cartilage, the slightest impairment of this fragile blood supply can lead to ischemia and necrosis. Cartilage exposure to aerodigestive pathogens is an aggravating factor⁷.

The main risk factors in cricoid chondronecrosis are those who compromise wound healing, such as peripheral vascular disease, diabetes mellitus, immunocompromised state and chronic glucocorticoid use. Multiple intubations and secondary tracheotomy are well known risk factors^6–8.

Cricoid chondronecrosis can occur at any age. In the literature, the reported ages of patients range from 8 months to 76 years. Dyspnea and inability to tolerate extubation are the most prominent symptoms. Also, some patients may have dysphonia or dysphagia⁹.

CT is the most commonly performed radiologic examination for a suspicion of cricoid chondronecrosis, it may show an hypodensity consistent with liquid, presence of air in the central lamina of the cricoid or disruption and fragmentation of the cricoid as it was the case in our patient.

The changes observed are nonspecific and sometimes overlap the imaging features of an infectious or neoplastic process. The clinical context, laboratory reports, and available histologic details help to exclude these conditions. Imaging features may be the only objective evidence of an abnormality when clinical examination data are nonspecific³. The endoscopic examination often reveals nonspecific elements signs such as glottic edema or granuloma formation. Impaired mobility of the vocal cords or, if visible, subglottic stenosis or granuloma⁹.

The management of cricoid chondronecrosis is not standardized and varies considerably in the literature. The first step is to secure the airways of patients, regardless of the etiology. In general, a tracheostomy should be performed as an emergency at the time of presentation, or later, when the patient has failed extubation.

Once the diagnosis of cricoid chondronecrosis has been made, endotracheal intubation-related chondronecrosis can be managed with steroids, nebulization, and physiotherapy^4,6.

Surgical approaches include airway dilation with CO₂ laser or balloon dilation¹⁰, a laryngotracheoplasty which consists of dividing the stenotic laryngotracheal segment in the sagittal plane and stabilizing the framework with autologous cartilage¹¹ or a posterior cricoid split that is described as an expansion of the posterior aspect of the cricoid with a costal cartilage graft¹². Some authors have reported the use of a Montgomery stent for 6–8 weeks with good outcomes related to airway caliber. However, even with optimal treatment, only few patients will eventually be able to be decannulated⁹.

Ethical approval

None.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

No funding was obtained for this study.

Authors’ contribution

B.W. drafted the manuscript. L.M. contributed to editing the manuscript. All remaining authors were involved in the care of the patients in this study, and editing the manuscript. All authors read and approved the final manuscript.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

Not available.

Guarantor

Walid Bijou.

Provenance and peer review

Not commissioned, externally peer-reviewed.