Tracheal breach revealed by post-operative facial edema: a case report

Post-intubation tracheal breach is rare but constitutes a serious postoperative complication following general anesthesia. Clinical manifestations are often non-specific, ranging from simple facial edema to acute respiratory distress, sometimes mimicking emergencies such as anaphylaxis. We report the case of a 43-year-old female, ASA I, scheduled for laparoscopic cholecystectomy, who developed progressive facial and cervico-thoracic edema three hours after extubation, initially suggesting an allergic reaction. Subsequent investigations including chest CT and bronchoscopy confirmed a tracheal rupture. The patient was successfully managed conservatively. This case emphasizes the importance of early differential diagnosis when confronted with unusual postoperative edema.

Introduction

Tracheal breach is a rare but potentially life-threatening complication of endotracheal intubation. It may be spontaneous, traumatic, or iatrogenic. Iatrogenic tracheal lesions (TL) after tracheal intubation occur in approximately 0.005% of cases, rising to 0.19% when a double-lumen tube is used (1).

Case report

A 43-year-old female (G2P2), ASA I, with no significant medical history, was admitted for elective laparoscopic cholecystectomy.

Preoperative evaluation revealed a stable patient with normal cardiopulmonary examination, no history of respiratory disease, no prior intubation-related complications, and normal laboratory tests. Airway assessment showed Mallampati II, normal thyromental distance, and good mouth opening.

General anesthesia was induced uneventfully. Intubation required three attempts due to limited laryngeal exposure. A 6.5-mm cuffed endotracheal tube was used. Cuff pressure was monitored and maintained at 25 cmH₂O. Intubation attempts lasted approximately 5 to 8 min in total. The intraoperative period proceeded uneventfully.

The patient was extubated fully awake after fulfilling standard recovery criteria, then transferred to the PACU. Two hours later, she was discharged to the surgical ward. Approximately one hour after transfer, she developed progressive facial edema involving the cheeks, neck, and upper chest. Anaphylaxis was initially suspected, but clinical examination revealed subcutaneous emphysema expanding over time.

The patient was readmitted to intensive care with mild polypnea and oxygen desaturation (SpO₂ 88%). Oxygen therapy was initiated alternating between nasal cannula and high-concentration face mask. Saturation gradually improved to 96%–97%, with serial arterial blood gases confirming appropriate oxygenation.

A chest X-ray showed pneumomediastinum and diffuse subcutaneous emphysema (Figure 1). A chest CT scan demonstrated extensive cervico-thoracic subcutaneous emphysema and suspected tracheal wall discontinuity (Figure 2). Bronchoscopy confirmed a posterior tracheal laceration in the upper third, classified as IIIb according to Cardillo's classification (2).

Figure 1

Figure 1. X-RAY: pneumomediastinum and subcutaneous emphysema.

Figure 2

Figure 2. CT SCAN CHEST: significant subcutaneous emphysema extending to the cervical level. Trachea site of partial filling with doubt about a solution of parietal continuity, pneumomediastinum.

Given the patient's stability, absence of large air leak, and well-oxygenated status, conservative management was initiated. Treatment consisted of:

- Systemic corticosteroids: methylprednisolone (Solumedrol®) at 1 mg/kg/day

- Alternating oxygen therapy (nasal cannula and high-concentration mask)

- Close clinical and radiological monitoring

The patient showed steady improvement. Subcutaneous emphysema regressed progressively. No signs of mediastinitis or respiratory deterioration occurred. She remained hemodynamically stable and was discharged from intensive care after six days. Follow-up was favorable.

Discussion

Post-intubation tracheal rupture, although rare, carries significant morbidity. Mechanical risk factors include inappropriate tube size, cuff overinflation, multiple intubation attempts, incorrect tube positioning, or intubation by inexperienced operators (3–5). Anatomical risk factors include female sex, advanced age, steroid use, congenital tracheal weakness, and COPD.

Clinical manifestations typically appear intraoperatively or early postoperatively and include subcutaneous emphysema, pneumomediastinum, pneumothorax, dyspnea, and hemoptysis (6). However, delayed presentations—several hours after extubation—have been described, leading to diagnostic confusion, as in our case.

Diagnosis relies on imaging, particularly CT, but bronchoscopy remains the gold standard for confirming the lesion and determining its extent (2).

Management can be surgical or conservative depending on lesion size, symptom severity, extension, and patient condition. Conservative management is increasingly favored, even for larger lesions, when oxygenation is preserved and no major complications coexist. Adjunctive treatments such as drainage of pneumothorax or mediastinal collections and antibiotic prophylaxis may support healing (7).

Conclusion

This case highlights the importance of considering tracheal rupture in any postoperative facial or cervico-thoracic edema, especially when subcutaneous emphysema is present. Early bronchoscopy is essential for diagnosis. Preventive strategies include gentle intubation, appropriate tube sizing, cuff pressure monitoring, and avoiding repeated forced attempts.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

Ethics statement

Ethical approval was not required for the study involving humans in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was not required from the participants or the participants legal guardians/next of kin in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the patient for publication of this report, as per the journals patient consent policy.

Author contributions

AD: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. JO: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. MS: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. FE: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. YZ: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

Funding

The author(s) declared that financial support was not received for this work and/or its publication.

Acknowledgments

We thank all the clinical staff who participated in treating the patient.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

1. Misak VB, Beraković AP, Vukusić I, Kogler J, Pazanin L, Ozegović SO. Postintubation tracheal injuries–case series and literature review. Acta Clin Croat. (2012) 51:467–71. PMID: 23330416

PubMed Abstract | Google Scholar

2. Lim H, Kim JH, Kim D, Lee J, Son JS, Kim DC, et al. Tracheal rupture after endotracheal intubation - a report of three cases. Korean J Anesthesiol. (2012) 62(3):277–80. doi: 10.4097/kjae.2012.62.3.277

PubMed Abstract | Crossref Full Text | Google Scholar

3. Miñambres E, Burón J, Ballesteros MA, Llorca J, Muñoz P, González-Castro A. Tracheal rupture after endotracheal intubation: a literature systematic review. Eur J Cardiothorac Surg. (2009) 35:1056–62. doi: 10.4097/kjae.2012.62.3.277

Crossref Full Text | Google Scholar

4. Lim H, Kim JH, Kim D, Lee J, Son JS, Kim DC, et al. Tracheal rupture after endotracheal intubation-a report of three cases. Korean J Anesthesiol. (2012) 62:277–80. doi: 10.4097/kjae.2012.62.3.277

PubMed Abstract | Crossref Full Text | Google Scholar

5. Stannard K, Wells J, Cokis C. Tracheal rupture following endotracheal intubation. Anaesth Intensive Care. (2003) 31:588–91. doi: 10.1177/0310057X0303100518

PubMed Abstract | Crossref Full Text | Google Scholar

6. Borasio P, Ardissone F, Chiampo G. Post-intubation tracheal rupture. A report on ten cases. Eur J Cardiothorac Surg. (1997) 12:98–100. doi: 10.1016/s1010-7940(97)00111-5

PubMed Abstract | Crossref Full Text | Google Scholar

7. Daffré E, Tricard J, Wurtz A, Conti M. Reevaluating the management of iatrogenic tracheal injuries. J Thorac Dis. (2025) 17(6):4371–3. doi: 10.21037/jtd-2025-522

PubMed Abstract | Crossref Full Text | Google Scholar