• A&A practice · May 2019

    Case Reports

    A Case Report of an Inadvertent Placement of Tracheostomy Tube Into the Pharynx After Emergency Tracheostomy: Management of a Failed Surgical Airway.

    • Motaz Awad and Saman Yaghoubian.
    • From the Department of Anesthesiology, New York Medical College, Westchester Medical Center, Valhalla, New York.
    • A A Pract. 2019 May 15; 12 (10): 362-365.

    AbstractInadvertent 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.

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