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\begin{document}

\title{Retained Tracheostomy Stay Suture with Migration into the Trachea: a
case report.}



\author[1]{James Johns}%
\author[2]{Andy Habib}%
\author[3]{Ronak Dixit}%
\affil[1]{Georgetown University Medical Center}%
\affil[2]{Georgetown University School of Medicine}%
\affil[3]{MedStar Washington Hospital Center}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\selectlanguage{english}
\begin{abstract}
The stay suture technique (SST) helps ensure safe replacement of the
tracheostomy tube after accidental decannulation. We describe a patient
found to have a retained stay suture in the glottis 2 weeks
post-decannulation. It is important to appreciate the possible
complications associated with SST, including airway compromise,
infection, and laryngospasm.%
\end{abstract}%



\sloppy


\textbf{Retained Tracheostomy Stay Suture with Migration into the
Trachea: a case report.}

Running Title: Airway Migration of Tracheostomy Stay Suture

\textbf{J. Dixon Johns, MD\textsuperscript{1}; Andy M. Habib,
MPH\textsuperscript{2}; Ronak B. Dixit, MD\textsuperscript{3}}

\textsuperscript{1}Department of Otolaryngology-Head and Neck Surgery,
MedStar Georgetown University Hospital, Washington, DC, United States.

\textsuperscript{2}Georgetown University School of Medicine, Washington,
DC, United States

\textsuperscript{3}Department of Otolaryngology-Head and Neck Surgery,
MedStar Washington Hospital Center, Washington, DC, United States.

\textbf{Funding and Conflict of Interest} : None

\textbf{Meeting Information} : Presented as poster presentation at
ABEA/COSM (Dallas, TX; April 29-May 1, 2022)

\textbf{Corresponding Author:}

J. Dixon Johns, MD

Resident Physician Department of Otolaryngology-Head and Neck Surgery
Georgetown University Medical Center Medstar Georgetown University
Hospital 3800 Reservoir Rd, NW Washington, DC 20007

Email: james.d.johns@medstar.net

\emph{Keywords:}

Tracheotomy, trachea, stay suture, decannulation

\textbf{Consent} : Written informed consent was previously obtained from
the patient to publish this report in accordance with the journal's
patient consent policy

\textbf{Key Clinical Summary:} We review the literature and present a
patient case wherein the tracheostomy stay suture migrated to the
airway. Although no significant complications arose, airway foreign
bodies present great risk for airway compromise, infection, or
laryngospasm.

\emph{Introduction}

Tracheostomy is a potentially life-saving procedure to secure a
patient's airway. There have been many techniques developed in order to
mitigate risks of tracheostomy tube displacement, including the
stay-suture technique (SST) and Bjork flaps, among others. SST refers to
the placement of sutures either around a tracheal ring or between the
skin and lower trachea to ensure correct replacement of the tube into
trachea in case of accidental decannulation and to reduce risk of false
passage. While SST has been shown to reduce mortality associated with
accidental decannulation, it also presents potential complications
associated with introducing foreign material in close proximity to the
airway. This report reviews the current literature regarding retained
tracheostomy stay sutures and highlights a unique presentation of a
patient with a retained tracheostomy stay suture in the airway following
decannulation.

\emph{Case Report:}

A 53-year-old male underwent surgical tracheostomy during
hospitalization for a cerebrovascular accident in April of 2021. During
the operation, three Prolene stay sutures were placed (one superior on a
trapdoor incision of the trachea, and one left, and one right). On
postoperative day 7, the tracheostomy tube was changed to a smaller
size. The stay sutures remained in place. Approximately three weeks
after surgery, the patient was ultimately discharged from the hospital
to a rehabilitation facility with the tracheostomy tube in place. He was
decannulated at the facility about six weeks after tracheostomy tube
placement without complication, although it is unclear if it was an
intentional or accidental decannulation. He was stable without the
tracheostomy and the facility opted not replace the tube, allowing the
stoma to close. He reported subjective hoarseness, but denied any other
issues after decannulation. A few weeks later, during fiberoptic
endoscopic evaluation of swallowing (FEES) with the Speech and Language
Pathology team at the rehabilitation facility, there was a string-like
object noted in his airway on exam, and the patient was sent to the
emergency department for further evaluation. At the hospital, the
Otolaryngology team performed flexible laryngoscopy in the emergency
department, which confirmed the presence of what appeared to be a
Prolene suture in the glottis. The patient's stoma had closed with
minimal granulation and no evidence of suture in the neck. The patient
was urgently taken to the operating room for direct laryngoscopy and
removal of the foreign body.

The patient was orotracheally intubated uneventfully. Upon inspection of
the glottis, a Prolene suture was seen sitting lodged between the
endotracheal tube cuff and the glottic airway (\textbf{Figure 1)} .
Using a 0-degree rigid telescope and grasping forceps, the suture was
grasped and easily removed. The cuff of the endotracheal tube was
deflated and the tube withdrawn for inspection of the trachea and
mainstem bronchi. Minimal inflammation was noted at the level of the
first and second tracheal ring. No further foreign body was identified.
The patient uneventfully recovered with no complication.

\emph{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
obstruction\textsuperscript{1}. 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)\textsuperscript{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)\textsuperscript{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)\textsuperscript{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)\textsuperscript{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.

\emph{Conclusion:}

SST is useful in preventing complications from accidental decannulation,
but as with all techniques, there can be drawbacks. Here we report an
additional case of a preventable complication related to SST. Although a
retained stay suture migrating into the airway rare, we feel that
bringing attention to this ``never event'' is important as tracheostomy
technique continues to evolve.

\emph{Acknowledgements}\textbf{:} None

\emph{References:}

1. Lee SH, Kim KH, Woo SH. The usefulness of the stay suture technique
in tracheostomy. \emph{Laryngoscope} . 06 2015;125(6):1356-9.
doi:10.1002/lary.25083

2. Rachakonda KS, Vangikar MM, Simmons EG. An intermittent foreign body
in the airway: a case report. \emph{Crit Care Resusc} . Sep
2001;3(3):173-5.

3. Joshi M, Budev M, Machuzak M. Retained sutures in the trachea.\emph{J
Bronchology Interv Pulmonol} . Jul 2010;17(3):236-7.
doi:10.1097/LBR.0b013e3181e64bcc

4. Brown DJ, Pitman MJ. Retained tracheotomy suture: nine years of
morbidity. \emph{Otolaryngol Head Neck Surg} . Apr 2010;142(4):626-7.
doi:10.1016/j.otohns.2009.11.022

\textbf{Figure 1:} Intraoperative endoscopic visualization of a retained
stay suture with migration into the airway at the level of the glottis\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

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