1

Introduction

Rupture of the trachea, although rare, is potentially life threatening. Most commonly, these injuries are caused by trauma or endotracheal intubation. Spontaneous tracheal rupture is very unusual, and the few case reports of such injuries that exist usually point to coughing as the causative factor . We report the first known case of spontaneous tracheal rupture due to vomiting alone.

2

Case report

A 14-year-old girl presented to an outside hospital with a 4-day history of generalized weakness, polydipsia, polyuria, nausea, and vomiting. She also reported shortness of breath and was found to be tachypneic. Finger stick glucose was 480, and chest x-ray revealed extensive subcutaneous air in the neck along with pneumomediastinum. She was subsequently transferred to the pediatric intensive care unit at our institution.

Pediatric otolaryngology was consulted for cervical emphysema and pneumomediastinum. Upon questioning, the patient and her family reported progressively severe vomiting over the last 4 days. Earlier in the day, after a violent episode of emesis, she became acutely short of breath. They denied any recent illness, trauma, intubation, or forceful coughing. Her past medical history was significant only for chronic ear disease requiring bilateral mastoidectomies. The patient was afebrile with normal blood pressure. Her respiratory rate was 39 breaths per minute with oxygen saturations of 94% on room air. Mild intercostal retractions were noted, but no stridor was appreciated. Extensive crepitus was palpable from her mastoid tips down to the xyphoid process. Her voice was strong and clear, there were no signs of cervical trauma, and the remainder of the examination was unremarkable. Flexible laryngoscopy showed a normal hypopharynx and larynx with no airway compromise. Laboratory values were remarkable for glucose of 320, mixed venous pH of 6.82, venous CO ₂ of less than 5 mmol/L.

A gastrograffin swallow showed no leak or obstruction. The computed tomography of neck and chest showed marked subcutaneous and mediastinal air ( Fig. 1 ) but no pneumothorax or blebs of the lung parenchyma. The esophagus was normal in appearance. However, a vertical posterior tracheal tear was seen 4.5 cm distal to the cricoid cartilage ( Fig. 2 ).

Computed tomography of head and neck revealing subcutaneous emphysema and pneumomediastinum.

Posterior tracheal tear located 4.5 cm distal to cricoid cartilage.

Because the patient was not in acute respiratory distress and saturating well with supplemental oxygen, the decision was made to observe the patient rather than to proceed with intubation. The most likely diagnosis was felt to be tracheal rupture caused by persistent forceful vomiting. At the recommendation of the pediatric intensivist, endoscopy was deferred because of the risk of anesthesia in her acidotic state. Pipericillin-tazobactam and metronidazole were begun empirically. The patient was rehydrated and started on an insulin infusion. One hundred percent oxygen was administered to promote absorption of the extravasated air. Our recommendations were for serial chest x-rays to monitor for worsening pneumomediastinum and intubation with the cuff distal to the site of injury if it became necessary, and bronchoscopy if necessary.

The patient’s ketoacidosis was controlled, and follow-up x-rays showed rapid improvement in the subcutaneous air and pneumomediastinum. Her tachypnea quickly improved over the first 24 hours. Intubation was not required. Her electrolytes and blood gas returned to normal. She tolerated a diet and was discharged home 8 days after admission.