INTRODUCTION: Endotracheal intubation is associated with complications that include laryngeal edema, ulceration, and glottic/subglottic granulation tissue formation. Such traumatic consequences can lead to respiratory difficulties. Here we report a unique case of traumatic intubation leading not only to respiratory difficulties while awake, but during sleep as well in the form of sleep disordered breathing.
CASE PRESENTATION: A 53 year old female smoker presented with syncope. Cardiac and neurological evaluation were normal. Upon further interview she reported excessive daytime somnolence, and a necessity to sleep sitting completely upright. Past medical history was notable for tracheostomy and subsequent decannulation after laryngeal fracture from a motor vehicle accident during childhood. Three years ago she required blind intubation while undergoing breast lumpectomy. The patient was extubated following the surgery, however, she was not spontaneously breathing. Emergent re-intubation was attempted unsuccessfully, and emergent cricothyroidotomy was required. Computed tomography (CT) of the neck post cricothyroidotomy displayed an edematous epiglottis. Treatment with corticosteroids was initiated and decannulation was performed 2 weeks later. Currently, physical examination revealed a normal body weight. The orophraynx was clear without palpable masses. There was a well healed tracheostomy scar, and of note, an inspiratory stridor was audible. Spirometry was performed, and revealed reduced inspiratory airflow with a visible plateau and flow oscillations, indicating a variable extrathoracic upper airway obstruction (Figure A). Nocturnal polysomnogram was performed to evaluate the daytime somnolence and revealed a plateau on the inspiratory airflow waveform with snoring indicating inspiratory flow limitation (Figure B). She was started on continuous positive airway pressure (CPAP) therapy to overcome the obstruction to airflow. Direct laryngoscopy was performed revealing redundant floppy supraglottic aryepiglottic mucosal fold with fluttering during respiration (Video), providing an etiology for the upper airway obstruction noted on both spirometry and nocturnal polysomnography. Supraglottoplasty was performed to remove the redundant tissue, resulting in resolution of her stridor and significant symptomatic improvement in her daytime somnolence.
DISCUSSION: Sleep disordered breathing (SDB) refers to abnormal breathing patterns during sleep. It is an increasingly common condition associated with obesity and results in significant morbidity and mortality. SDB includes obstructive sleep apnea (OSA), which is characterized by episodes of apnea or hypopnea as a result of partial or complete obstruction in the upper airway during sleep. The obstruction is typically caused by relaxation of pharyngeal muscles during sleep that result in the palate and tongue obstructing the airway in the supine position. Here we report a unique cause of acquired obstructive sleep apnea and sleep disordered breathing in a thin adult. In this case, traumatic intubation during an elective procedure resulted in trauma to the supraglottic larynx. The resulting granulation tissue and redundant mucosa interfered with normal inspiration during wakefulness as well as during sleep as evidenced on the flow volume loop and nocturnal polysomnogram, respectively.
CONCLUSIONS: We report a novel case of daytime somnolence and sleep disordered breathing secondary to obstruction from redundant supraglottic mucosa following traumatic intubation.
Reference #1 Terry Young et al. The Occurrence of Sleep-Disordered Breathing among Middle-Aged Adults. N Engl J Med 1993; 328:1230-1235.
DISCLOSURE: The following authors have nothing to disclose: Deepak Pradhan, Seth Lieberman, Kenneth Berger
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