CASE REPORT
The patient was a 54-year-old male who is diagnosed with squamous cell carcinoma of the right vocal cord for which he had undergone microlaryngeal surgery along with tracheostomy for the same in July 2012. He then underwent intensity modulated radiotherapy. Since then, the patient has been on tracheostomy tube. Patient was decannulated following laryngoscopic assessment on April 2015. A strapping was done to seal the tracheostome. A month later, on follow up, the tracheostome was found to be still patent with an air leak (Figure 1). A secondary suturing was attempted to close the fistula. Despite this attempt the fistula persisted due to his chronic cough. The patient was then posted for a flap cover to close the fistula. After admission for the same, he developed severe bronchitis for which he was treated medically. A bronchoscopy showed inflammed bronchus and a broncheo-alveolar lavage showed pseudomonas aeruginosa growth for which he was treated with culture sensitive antibiotics and steroids. During this course, he developed steroid induced hyperglycemia with a derangement of his renal parameters and was under the diabetologist and nephrologist care. Post recovery and after getting the medical clearance, he underwent a Pectoralis Major Musculocutaneous Flap cover in June 2015 (Figure 2). On the first post op day, he had an episode of transient unresponsiveness with stable vitals. He had no chest pain or hypoglycemic episodes. Examination revealed bilateral subcutaneous emphysema over the chest and face. Chest Xray showed no signs of pneumothorax. Screening ECHO showed a good LV systolic function with no pericardial effusion or evidence of Acute Coronary Syndrome. Blood test for troponin T was negative. He was closely monitored in the Intensive Care Unit. He also received a unit of packed cells for his drop in hemoglobin post op. he was discharged from the hospital and was advised to follow up in the OPD for dressing. After a week from discharge, he came to the OPD with complaints of pain in the surgical donor site of the flap. Examination revealed an abscess at the surgical site which was drained and the pus was sent for culture which later reported as carbapenem resistant enterobacteria (Figure 3). He was treated with IV antibiotics and daily dressing of the surgical site wound was done. After 10 days the wound healed well and was later discharged from the hospital.