Intrathoracic Tracheal Obstruction Caused by a Carotid Mycotic Aneurysm in a Patient with Deep Neck Infection – A Case Report

Abstract

Upper airway obstruction secondary to a carotid mycotic aneurysm has not been previously reported. We describe a patient with a mycotic aneurysm associated with a deep neck infection and presenting with acute tracheal obstruction. Recognition of this condition is important to avoid inadvertent rupture of the aneurysm in the course of diagnostic aspiration or surgical drainage. Physical findings, including a pulsating mass and an arterial bruit, in addition to appropriate imaging studies, may be helpful in suggesting the diagnosis. In particular, both neck and chest contrast-enhanced computed tomography scans may give important clues to the presence of a vascular lesion. In a patient with an infected neck mass and tracheal compression, a common carotid mycotic aneurysm should be considered in the differential diagnosis.

Airway management in vascular central airway obstruction: a literature review

“…Table 3 shows acquired extrinsic vascular CAO caused by arterial aneurysm of central vascular system or extremely thoracic anatomy. Arterial aneurysms of the innominate artery [20,26,[67][68][69][70][71], ascending aorta [71][72][73][74], aortic arch [73][74][75][76][77][78], descending thoracic aorta [74][75][76][79][80][81][82][83][84], and common carotid artery [85][86][87]] that compress the central airway are secondary to atherosclerotic degeneration [20,68,69,[73][74][75][76][82][83][84], heritable connective tissue disease [77][78][79][80], infection process [67,81,85,86,…”

“…Aortic aneurysm of ascending aortic [71][72][73][74] Aortic aneurysm of aortic arch [73][74][75][76] Aortic aneurysm of thoracic aorta [74][75][76][82][83][84] Aneurysm of innominate artery [20,26,[68][69][70] Aneurysms of the ascending aorta and innominate artery [71] Ruptured thoracic aortic aneurysm [23] Heritable connective tissue disease Aortic aneurysm of thoracic aorta in Marfan's disease [77][78][79] Aortic aneurysm of thoracic aorta and innominate artery in Marfan disease [79] Aortic aneurysm of thoracic aorta in heritable connective tissue disease [80] Aortic dissection Dissected internal carotid artery [87] Dissected descending aorta [89] Infection process Mycotic common carotid aneurysm (Staphylococcus aureus) [85,86] Mycotic descending aortic aneurysm (Staphylococcus aureus) [81] Syphilitic aortic arch aneurysms [88] Syphilitic innominate aneurysms [67] Pulmonary artery system Pulmonary artery aneurysm [90,91] Pulmonary artery pseudoaneurysm [91] Pulmonary artery dilation [92][93][94] Extremely abnormal thoracic anatomy [95] Severe kyphoscoliosis resulting in trachea compressed by the innominate artery anteriorly and thoracic spine posteriorly in Marfa...…”

“…Trachea and extrapulmonary bronchi are composed of hyaline cartilage that is resistant to external compression. When intrinsic wall weakness of the airway [86] or high external pressure that over the air column can stand, extrinsic CAO occurs [82]. Therefore, some patients present with asymptomatic vascular CAO [47][48][49]56], and the others commonly demonstrate chest discomfort, including chronic cough, recurrent bronchopulmonary infections, stridor, hoarseness, and wheezing [27,40,53,76].…”

“…Surgical reconstruction is required to cure vascular CAO [8,19,20,62,71]. Antibiotics are essential for mycotic aneurysm [81,85,86]. However, prompt airway management for vascular CAO is critical for the success in the treatment (Table 5).…”

“…Difficult intubation [56], persistent hypercapnia with/or without oxygen desaturation after trachea intubation [26,75], difficulty in passing through the suction tube [75,79], difficulty in weaning from mechanical ventilation [79], and extubation failure that presents with smooth breathing when using endotracheal tube but becoming airflow limitation soon after remove the endotracheal tube [59,79,86] should be signs that alert doctors to exclude the possibilities of vascular CAO. Mechanical ventilation variability is another sign of tracheal compression [26,75,81,109], which explains why the patients with CAO still present with low tidal volume, hypercapnia, and arterial oxygen desaturation under the assistance of artificial positive-pressure ventilation.…”