# Unexpected Difficult Intubation Reveals Congenital Tracheal Stenosis in an Adult During Anesthesia Induction for Gastroesophageal Junction Cancer Surgery

## TL;DR

A 75-year-old woman with asthma had unexpected difficulty during intubation, revealing undiagnosed congenital tracheal stenosis, highlighting the need for thorough preoperative assessments.

## Contribution

This case highlights the importance of preoperative imaging and evaluation for undiagnosed congenital tracheal stenosis in adults.

## Key findings

- Congenital tracheal stenosis was unexpectedly detected during intubation in an adult with a history of asthma.
- Preoperative chest X-rays showed mild tracheal narrowing but failed to diagnose the condition.
- Use of a bronchial blocker and single-lumen tube enabled successful anesthesia management.

## Abstract

We encountered a case of congenital tracheal stenosis (CTS) in an adult, which was unexpectedly detected during a difficult endotracheal intubation. The patient was a 75-year-old female who was admitted to our hospital for surgery for esophagogastric junction cancer. She had a 15-year history of asthma. A preoperative chest X-ray showed slight narrowing of the trachea, but at that time, a diagnosis of tracheal stenosis could not be made. General anesthesia was induced for the planned surgery, and the anesthesiologist attempted oral endotracheal intubation with a double-lumen tube. However, the attempt was unsuccessful. Narrowing of the trachea began at the level of the first rib attachment, with the tracheal rings forming a complete ring-like structure in the bronchoscope. Intubation was successfully performed using a 7-mm single-lumen tracheal tube, and anesthesia management was carried out with the use of a bronchial blocker. While most cases of CTS are diagnosed in childhood due to symptoms of airway obstruction or congenital heart disease, CTS patients with relatively mild stenosis may remain asymptomatic or undiagnosed into adulthood. Although CTS is a rare condition, it can lead to unexpected difficulty in intubation or multiple attempts of tracheal intubation, requiring caution. Preoperative evaluation, including the presence of respiratory conditions such as asthma, and the potential utility of chest X-rays and computed tomography scans for detecting CTS, were considered essential for careful preoperative assessment.