A Missed Diagnosis of Laryngotracheal Injury Secondary to Emergency Intubation: Lessons Learned

Dam, V Sha Kri Eh; Mohamad, Sakinah; Hassan, Nik Fariza Husna Nik; Mazlan, Mohd Zulfakar

doi:10.14712/18059694.2022.27

Acta Medica > Archive > 2022, Vol. 65 > Issue 3 > A Missed Diagnosis of Laryngotracheal…

Acta Med. 2022, 65: 112-117

https://doi.org/10.14712/18059694.2022.27

A Missed Diagnosis of Laryngotracheal Injury Secondary to Emergency Intubation: Lessons Learned

V Sha Kri Eh Dam^a,b, Sakinah Mohamad^a, Nik Fariza Husna Nik Hassan^c, Mohd Zulfakar Mazlan^d

^aDepartment of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia Health Campus, 16150 Kota Bharu, Kelantan, Malaysia
^bDepartment of Otorhinolaryngology-Head & Neck Surgery, Hospital Tengku Ampuan Rahimah, Jalan Langat, 41200 Klang, Selangor, Malaysia
^cSpeech Pathology Programme, School of Health Sciences, Universiti Sains Malaysia Health Campus, 16150 Kota Bharu, Kelantan, Malaysia
^dDepartment of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia Health Campus, 16150 Kota Bharu, Kelantan, Malaysia

Received September 6, 2021
Accepted October 30, 2022

Iatrogenic laryngotracheal trauma is a potentially fatal complication of endotracheal intubation, especially in an emergency setting. Symptoms are almost always related to speech, breathing, and swallowing. Hoarseness being the commonest symptom, while shortness of breath and stridor always signify more devastating injury. We present a case of iatrogenic subglottic and tracheal stenosis, which was misdiagnosed in the emergency department during the first visit. This case report highlights the importance of salient history and thorough examination with a high index of suspicion in a stridorous case with a recent history of intubation. Early detection and management are vital to avoid a life-threatening event.