In Response to <i>Thyroid Cartilage Fracture Following Endotracheal Intubation</i>

We thank Khanna et al. for their insightful comments. Our paper was intended as a report of a highly unusual problem of intubation rather than a comprehensive review of other intubation-related injuries. We suspect injury occurred after using the videolaryngoscope, as ventilation through the endotracheal tube (ETT) was difficult afterwards and the exchange of the ETT over a bougie introducer resulted in buckling of the tube, suggesting the tip of the tube was in the false tract subglottically. Force used by the anesthesiologists would be conjectural. Anterior cricoid pressure was used but the number of attempts at intubation by the anesthesiology team is difficult to gauge and not recorded. The silicone EMG tube used is softer than standard PVC, and the subglottic injury was likely caused by the rigid stylet. Flexible tracheoscopy was performed to intubate atraumatically by the otolaryngology team. CT scanning was not available intraoperatively, nor was a thyroid cartilage fracture suspected. The subcutaneous emphysema noted later was subtle and detected by palpation. As our service manages laryngeal trauma at a level one trauma center [1], the nondisplaced thyroid cartilage fracture was recognized during surgery. We typically do not perform subsequent CT scans for uncomplicated isolated nondisplaced fractures in closed or open cases. To prepare for thoracotomy, Ancef was given preoperatively and Flagyl was added when the subglottic perforation was discovered. Antibiotics were continued postoperatively without infection. At 5 months post-procedure, there was intact laryngeal motion, a mid-glottic synechia, and dysphonia prompting a referral to our laryngologist. The anesthesia team had experience and confidence in handling difficult airways. It is our experience that our otolaryngology team is sometimes able to secure an airway when the anesthesiology team is not, and vice versa. Other than the intubation injury, there were no postoperative complications specifically related to thyroidectomy or thoracotomy such as hypoparathyroidism. We contend that our management was the safest for this morbidly obese patient with a massive goiter distorting the airway anatomy rather than prematurely attempting an awake tracheostomy which may result in exacerbation of subcutaneous emphysema following mask ventilation, increased risk of infection given concomitant sternotomy, and operative difficulties especially with the need for subsequent massive substernal thyroidectomy. Tracheostomy also hinders the use of closed suction drains unless modified with fenestration techniques [1]. Finally, difficult airway algorithms/guidelines with “early transition to … awake tracheostomy” are usually used to address airway obstruction causing hypoxia, which was not the case herein. The authors have nothing to report. The authors declare no conflicts of interest. Data is not available as it would represent a breach in confidentiality.