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.