Improved percutaneous transtracheal ventilation for airway obstruction in tongue cancer: a case report

Introduction

Tongue cancer is one of the most common oral malignancies. In its advanced stages, tumor progression and treatments such as surgery and radiation result in significant anatomical changes in the oral cavity and pharynx, including scarring and fibrosis (1). These changes complicate airway management, particularly in emergency situations. Rapid decision-making and adaptability are crucial for clinicians dealing with airway obstruction due to bleeding or tumor recurrence (2). Despite advancements in airway management, effective strategies remain insufficient for cases involving acute hemorrhage and complex anatomical distortions. This report introduces an enhancement to percutaneous tracheal ventilation—incorporating intermittent oral-nasal occlusion—employed in the emergency airway management of advanced tongue cancer with hematemesis. To our knowledge, this technique has not been previously documented. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-101/rc).

Case presentation

In February 2023, a 66-year-old male was diagnosed with carcinoma of the right side of the tongue. In March, he underwent a partial glossectomy, right cervical lymph node dissection, and temporary tracheostomy. Postoperative histopathological analysis confirmed lymph node metastasis, indicating locally advanced disease. The patient subsequently received chemoradiotherapy from April to September 2023. A follow-up MRI conducted in May 2024 suggested potential tumor recurrence in the oropharynx. On July 19, 2024, the patient presented to the oncology department with symptoms of fatigue and dysphagia. On July 23, 2024, the patient experienced a sudden episode of hematemesis (approximately 200 mL), followed by cyanosis and acute respiratory distress. Initial vital signs revealed a blood oxygen saturation (SpO₂) of 44%, a heart rate of 133 beats per minute, and a blood pressure of 92/50 mmHg. Efforts to maintain airway patency through patient repositioning and removal of blood clots were unsuccessful in stabilizing oxygenation. We attempted positive pressure ventilation via mask but encountered significant resistance. Despite the application of maximum positive pressure, SpO₂ only increased to 80%.

Multiple attempts at conventional intubation techniques, such as direct laryngoscopy and fiberoptic bronchoscopy, were unsuccessful due to anatomical distortion, restricted mouth opening, and significant bleeding that obscured visibility. During these procedures, the patient’s SpO₂ decreased to 70%, necessitating the medical team’s decision to perform a percutaneous transtracheal ventilation (PTV).

Given the ambiguity of anatomical landmarks and the presence of tracheostomy scars, we employed an 18 G needle in conjunction with a 20 mL syringe to puncture the cricothyroid membrane just superior to the scar. Subsequently, the 18G needle was connected through an extension tube to a wall-mounted oxygen flow meter, calibrated to deliver oxygen at a rate of 10 L/min, thereby establishing a high-flow oxygen delivery system that elevated SpO₂ to 92% (Figure 1). This intervention was a temporary measure, and the treatment team acknowledged the necessity for a complex tracheostomy, which was anticipated to require an extended duration. In light of the patient’s limited chest wall movement, inadequate tidal volume, and the potential for carbon dioxide retention, it was imperative to optimize the current respiratory situation. Observing significant gas leakage through the mouth and nose, we employed intermittent oral-nasal occlusion, intermittently occluding the patient’s mouth and nose for three seconds and then releasing for three seconds. This approach simulated a respiratory rate of ten breaths per minute and balanced adequate oxygenation with the risk of barotrauma from prolonged airway pressure. The calculated tidal volume was approximately 500 mL, derived from the equation [10 L/min × (3 s/60 s) = 500 mL], yielding a minute ventilation of 5 L/min. Intermittent oral-nasal occlusion resulted in observable chest wall movement, indicating effective ventilation, and the patient’s SpO₂ increased to 100% (Figure 2). Following the establishment of adequate oxygenation and ventilation, the surgical team successfully performed the complex tracheostomy after one hour of effort (Figure 3). Importantly, no electrocautery was used during the tracheostomy due to the high-flow oxygen environment. This decision was made to prevent the risk of an airway fire, which is a well-known but potentially overlooked hazard in such settings. Subsequently, the patient was transferred to the intensive care unit, where recovery was satisfactory, with no indications of hypoxic brain injury or cerebral edema. Postoperative imaging showed severe airway stenosis, with an airway diameter of 2.76 mm (Figure 4).

Figure 1 Schematic diagram and photograph of the percutaneous tracheal puncture ventilation system. (A) A schematic diagram illustrating the connection between the 18 G needle and the oxygen supply via extension tubing. (B) A photograph taken during the implementation process.

Figure 2 Illustration of the intermittent oral-nasal occlusion technique during emergency tracheostomy. (A) A diagram illustrating the technique of intermittent oral-nasal occlusion using a face mask. (B) A photograph from the actual resuscitation scenario, showing the use of a face mask to regulate the closure and opening of the upper airway during emergency tracheostomy.

Figure 3 Post-tracheostomy completion.The image is published with the patient’s consent.

Figure 4 A postoperative computed tomography scan revealing significant airway stenosis, with an airway diameter measured at 2.76 mm. The yellow arrow indicates the location of the airway.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Emergency airway management in patients with advanced tongue cancer poses considerable challenges, primarily attributable to anatomical alterations and hematemesis (3). As outlined in the 2022 practice guidelines by the American Society of Anesthesiologists (ASA), a swift transition to invasive techniques is advised when non-invasive methods prove ineffective (4). Among the invasive techniques, emergency tracheostomy is regarded as a relatively safe and dependable approach for airway management; however, it necessitates that the patient maintains relatively stable vital signs. In instances where patients present with complex and atypical cervical airway anatomy, this procedure may require an extended duration. Consequently, PTV is frequently employed as a temporary measure to allow time for subsequent optimization of ventilation (5).

In this case, both conventional intubation and ventilation techniques proved ineffective, we promptly chose to implement PTV as a temporary intervention to ensure adequate oxygenation. Due to anatomical distortion, the needle technique offered more flexibility in limited operative space, whereas cricothyroidotomy could require more time and present greater procedural risk if unsuccessful. However, with SpO₂ barely maintained at approximately 90% and tidal volume deemed inadequate, the risk of carbon dioxide retention was significantly elevated, potentially resulting in a series of adverse outcomes. The primary limitation of prior percutaneous transtracheal ventilation techniques is their suboptimal efficacy in high-flow ventilation scenarios or the requirement for a high-pressure oxygen jet device. In resource-constrained environments, oxygen administered through the puncture in patients with partial airway obstruction may escape via the oral and nasal cavities. To mitigate this, we employed intermittent oral-nasal occlusion, which facilitated oxygen accumulation and generated positive pressure within the airway, thereby enhancing lung ventilation (Figure 2). This intermittent oral-nasal occlusion effectively minimized the risk of airway barotrauma. Intermittent oral-nasal occlusion represents an innovative approach that further optimizes respiratory efficiency in emergency situations. However, this method requires a dedicated operator to perform intermittent occlusion, which may limit its feasibility in mass casualty situations or when only a single provider is available. Additionally, improper timing of occlusion and release may result in air trapping and reduce ventilation efficiency. Further prospective studies or simulations could help determine optimal occlusion/release timings and validate efficacy across different causes of airway obstruction.

Furthermore, the tools employed in this case were among the most readily accessible items within the ward (Figure 5), thereby underscoring the applicability of this methodology in resource-constrained settings.

Figure 5 Essential equipment for the percutaneous transtracheal ventilation combined with the intermittent oral-nasal occlusion technique, including a 20 mL syringe with an 18 G needle, a face mask, an infusion extension tube, and an oxygen inhalation catheter.

Conclusions

The management of emergency airways in patients with advanced tongue cancer and hematemesis poses considerable challenges. This case study illustrates that the integration of fine-needle cricothyroid puncture with intermittent oral-nasal occlusion may serve as an effective strategy for sustaining pulmonary ventilation and oxygenation, particularly in resource-constrained environments. This method provides a viable solution for addressing complex airway management in emergency contexts.

Acknowledgments

We would like to thank the patient and his family for their cooperation and trust throughout the treatment process.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-101/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-101/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-101/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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