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.