Tracheomalacia; a possible systemic effect of chronic steroid use

Background: Tracheomalacia is a structural deficit of the tracheal cartilages inducing excessive collapsibility of the trachea. Origin: Acquired conditions more common in adults. Case report: A report of a 23year old lady who presented with a benign, simple small sized goiter of 9 months duration scheduled for thyroidectomy. She had no retrosternal extension, pressure symptoms or features of respiratory insufficiency. Patient had thin, fragile depigmented (bleached) skin with discolouration. She had extensive skin striae (stretch marks) on the trunk, abdomen and pelvic region despite having s slim stature. She had been using a potent skin whitening cream containing two potent topical steroids for about 3 years. Prior to surgery, patient had intravenous exogenous dexamethasone to prevent the potential risk of the suppression of the hypothalamo-pituitary-adrenal axis with a subsequent inappropriate response to surgery. Intra-operatively the lead surgeons had called the teams’ attention to the abnormal anatomy of the patients’ trachea. The lumen of the trachea appeared narrowed as evidenced by the reduced anterior-posterior airway caliber with associated loss of the semicircular shape of the tracheal rings and bulging of the posterior membranous wall. The diagnosis of tracheomalacia was made and an emergency tracheostomy was performed. The endotracheal tube was extubated after proper suctioning. Surgery was concluded and patient was transferred to the high dependency unit for close monitoring. The serum cortisol and urinary cortisol levels were elevated (28mcg/dl and 55mcg/day respectively). This report highlights the unusual presentation of this patient and emphasizes the place of interprofessional team work required in her management. Conclusion: Tracheomalacia is a life threatening condition that is mostly of acquired origin in adults. Chronic use of topical steroids has been associated with systemic complications such as atrophy, and weakening of airway cartilages but these effects has been sparsely discussed or documented in literatures particularly relating to anaesthesia. This report presents an unusual presentation of suspected tracheomalacia secondary to chronic use of topical steroids.