An unusual early onset post-intubation tracheal stenosis

Upper airways stenosis is a rare complication of the intubation which has been reported to occur about 30 days after the extubation. We report a case of inflammatory, membranous subglottic stenosis developed two days after oro-tracheal extubation. A 70-year-old woman underwent elective L4-L5 surgical decompression. Two days later, she suddenly developed severe dyspnea and felt abundant tracheo-bronchial secretions, that she was unable to expectorate. Vital signs rapidly deteriorated and gas exchanges progressively worsened. Bronchoscopy was urgently performed. The tracheal inspection disclosed a severe, concentric subglottic stenosis. The occluding diaphragm was then radially incised and balloon dilation performed in order to warrant airways security. The procedure was then completed, and the soft occluding tissue was first cleaved from the tracheal wall and finally removed en-bloc through a dedicated V-shaped grasping forceps. Despite the diaphragm-like, concentric, morphology, the removed cylindered formation shared several pseudomembranous-like features with a pathologic report describing a mucofibrinous structure containing a large number of inflammatory, prevalently neutrophilic granulocytes and, surprisingly, fibroblasts cells with early sign of keloidal fibrosis. In conclusion, fibro-inflammatory tracheal stricture may occur within 48 hours after extubation and can, most of the times, be safely removed through flexible bronchoscopy. Being this the case, it is likely that the stenosis shares relevant similarities with tracheal pseudomembranes and requires en-bloc removal.