A 68-yr-old man with invasive thyroid cancer underwent thyroidectomy and tracheal resection. Two days postoperatively, he developed increasing respiratory distress. Examination of his neck showed a subcutaneous air pouch (indicated by arrows), which alternately inflated during expiration (panel A) and deflated during inspiration (panel B).

Tracheocele describes an air pocket in the neck that communicates with the tracheal lumen. Although it may be congenital, it most commonly results from surgeries involving the trachea such as tracheostomy, tracheal resection, and tracheocutaneous fistula repair.1 

Anatomically, this unusual breathing pattern occurs because rigid tracheal rings hold patent a tracheal defect throughout the respiratory cycle that allows both the exit and the re-entry of expired air to the trachea. Physiologically, the subcutaneous reservoir increases work of breathing by adding significant dead space, eventually leading to hypercapnia, hypoxemia, and respiratory failure.

Computed tomography may aid in diagnosis2  (panel C) but does not consistently show the small fistula tract. Similarly, bronchoscopy is often required for confirmation, but the view can be impeded by the endotracheal tube (ETT) itself. Detection of this characteristic bullfrog-breathing pattern should raise the suspicion of a tracheal air leak after cervical surgery.

Treatment includes drains with pressure dressings for asymptomatic patients, whereas surgical repair is required for symptomatic patients. Positive pressure ventilation may lead to serious air leak and subcutaneous emphysema. Intraoperative airway management should include spontaneous ventilation, bronchoscopy for intubation, and positioning of the ETT cuff distal to the defect.3  A video of the tracheocele can be viewed in Supplemental Digital Content (http://links.lww.com/ALN/C686).

The authors declare no competing interests.

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