Ultrasound for Diagnosing Tracheal Necrosis: A Case Report

Tracheal necrosis following endotracheal intubation is a rare but life-threatening condition that compromises airway patency. This case report highlights the novel use of upper airway ultrasound (USG) for its diagnosis. A middle-aged male smoker presented with a 2-week history of productive cough, noisy breathing, and exertional dyspnea. He had been intubated a month earlier for traumatic brain injury and treated for Streptococcus mitis bacteremia. Examination revealed mild tachypnea, stridor, and oxygen saturation between 90–95%. Blood tests showed elevated C-reactive protein (6 mg/dL) but normal white cell counts, with no acidosis or hypoxia on arterial blood gas analysis. Flexible laryngoscopy identified thick mucopus below the vocal cords with necrotic tracheal cartilage and debris obstructing the airway. A bedside upper airway USG revealed irregular, jagged air-mucosal interface (AMI) and comet tail artifacts at the 1st and 2nd tracheal rings. These findings suggested necrotic cartilage and impending airway obstruction. The patient underwent successful treatment with parenteral antibiotics, wound debridement, and tracheostomy. This case demonstrates that USG provides crucial real-time imaging of the upper airway, detecting irregularities in the air-mucosal interface and assisting in early diagnosis. Tracheal necrosis, caused by factors such as prolonged intubation, high cuff pressure, and underlying conditions like diabetes, poses significant airway management challenges. Timely intervention with airway stabilization, necrotic tissue debridement, infection control, and supportive care is essential to prevent complications like tracheal stenosis or perforation. This case underscores the potential of upper airway USG as a valuable tool in the early detection and management of tracheal necrosis, offering a non-invasive, bedside diagnostic modality to guide clinical decisions and improve outcomes.