Discussion
This case reports a patient with a retained tracheostomy stay suture
that migrated into the airway. Although there were no significant
complications associated with the patient presentation, airway foreign
bodies present great risk for airway compromise as well as possible
nidus for infection or laryngospasm. Retained foreign bodies, especially
in proximity to the airway, are an example of a surgical “never
event.” Although stay sutures are intentionally left in place following
tracheostomy, it is of utmost importance to ensure removal when the
stoma has matured and the sutures are no longer indicated. While an
uncommon complication in the literature, this report highlights
importance of accounting for all foreign materials during management of
the airway even in the weeks after the procedure is completed.
Accidental tracheostomy tube decannulation presents a life-threatening
complication, with incidence rate reported between 0.35-2.7%, with
tracheostomy complication mortality rates ranging from 0.5-3%, due
primarily to accidental decannulation and tube
obstruction1. SST represents a procedure to reduce the
risk of mortality associated with accidental decannulation. One study
compared SST vs. traditional tracheostomy without SST, finding that SST
(n = 104) experienced no deaths while traditional tracheostomy had 3
deaths due to unexpected decannulation (n = 101, p =
0.024)1. While SST may reduce adverse events due to
accidental decannulation, the risks of this technique must be taken into
consideration including presumed increased operative time to place the
stay sutures as well as the risk of retained foreign body.
There are only three other case reports in the literature describing
migration of a tracheostomy stay suture into the airway. Rachakonda et
al. (2001)2 describes a patient who required surgical
tracheostomy placement following vehicular trauma and subsequently
downsized to a fenestrated tracheostomy tube. In the week following tube
exchange, patient experienced increased secretions, tachycardia,
hypertension and hypoxia, with nursing staff noting string material
extruding from tracheostomy tube. Upon examination of tracheostomy tube
during partial removal, it was noted that the stay suture had migrated
into the stoma through the fenestration in the tracheostomy tube.
Another report by Joshi et al. (2010)3 describes a
patient who had a history of tracheostomy tube placement following
hypercapnic respiratory failure with subsequent successful decannulation
who had incidental anterior tracheal mucosal irregularity on routine
chest imaging for lung transplant evaluation. Flexible bronchoscopy
revealed retained suture material at the previous tracheostomy site from
retained stay suture. Brown et al. (2010)4 describe a
patient complaining of throat irritation and cough nine years following
decannulation of a tracheostomy tube. In office flexible laryngoscopy
revealed a suture extending from tracheal wall through the glottis.
While in all cases the suture material was removed without complication,
each case, including our own, required an extra procedure under general
anesthesia, which could have been prevented with proper postoperative
care.