Tracheostomy in patients with cervical rib: a note of caution.

Abstract

Cervical rib is a congenital phenomenon that usually occurs in association with upper-limb neurovascular symptoms. The presence of a cervical rib displaces the great vessels that cross the thoracic outlet superiorly and proceed into the neck. We report an unusual case of iatrogenic hemorrhage during a tracheostomy in a patient whose right subclavian artery had been displaced by a cervical rib. Our aim is to alert surgeons to the hidden risks of this phenomenon.

Introduction

Cervical rib is a congenital bony abnormality in which a superfluous rib forms superior to the first rib. This condition frequently leads to thoracic outlet syndrome, a set of symptoms that may be caused by compression on the brachial plexus and on the subclavian vessels in the region of the thoracic outlet. (1) Congenital bony abnormalities such as cervical rib are often responsible for the arterial complications of this syndrome (e.g., aneurysm). (2)

In this article, we describe a case of iatrogenic hemorrhage during a tracheostomy that was caused by artery displacement by a cervical rib.

Case report

A 77-year-old woman came to us with severe stridor of 8 hours' duration. She had been bedridden with left hemiplegia following a cerebrovascular accident 2 years earlier. She had type 1 diabetes, but it was uncontrolled because she did not properly follow her insulin regimen. On casual observation, her condition was one of impending collapse. She exhibited the use of accessory muscles, perspiration, and signs of lethargy.

She was rushed to the operating theater without further investigation because of the precarious nature of her airway, and an emergency tracheostomy was performed under local anesthesia. The incision was made halfway between the cricoid cartilage and the suprasternal notch and deepened layer by layer. After we identified the thyroid gland, we displaced it superiorly with a thyroid hook. This maneuver resulted in profuse hemorrhage.

With some difficulty, we were able to arrest the bleeding and ligate the vessel. It was then that we noticed that a large artery crossed the right anterior half of her trachea and arched into the right supraclavicular region. The bleeding had come from a superior branch of this large artery. We then realized that the large vessel was the right subclavian artery and the bleeding vessel was the thyrocervical trunk. The tracheostomy was completed, and the patient was made comfortable. Direct laryngoscopy revealed that the supraglottis was injected and edematous. A diagnosis of supraglottitis was made.

A postoperative chest x-ray revealed the presence of a right cervical rib (figure). The patient recovered uneventfully with antibiotics and regular insulin to control her diabetes.

[FIGURE OMITTED]

Discussion

In the presence of cervical rib, the subclavian vessels and brachial plexus have been classically described as always arching over it. (3) During a tracheostomy, the hyperextension of the neck would further arch the subclavian vessels superiorly.

In our patient, it is probable that the right subclavian artery was superiorly displaced into the surgical field by a combination of the cervical rib and the neck extension. In a patient with such an abnormality, the risk of surgical complications during an emergency tracheostomy would be substantially increased. Therefore, we report this case to issue a note of caution to surgeons. A chest x-ray should be routinely obtained before any tracheostomy.

References

(1.) Davidovic LB, Lotina SI, Vojnovic BR. et al. [Treatment of the thoracic outlet vascular syndrome]. Srp Arh Celok Lek 1998:126: 23-30.

(2.) Aburahma AF. White JF III. Thoracic outlet syndrome with arm ischemia as a complication of cervical rib. W V Med J 1995;91: 92-4.

(3.) Kosenak LM, Knorr EJ, DeRojas JJ, Katlic MR. Cervical rib variant: Report of a case. Ann Vase Surg 1992;6:292-3.

From the Department of Otolaryngology, University of Malaya Medical Center, Kuala Lumpur, Malaysia.

Reprint requests: N. Prepageran, Department of Otolaryngology, University of Malaya Medical Center. 50603 Kuala Lumpur, Malaysia. Phone: [phone]; fax: [phone]; e-mail: [e-mail]