A thirty-five-year-old male patient underwent elective total thyroidectomy and bilateral level 2–7 neck dissection for a primary right medullary thyroid cancer with preoperative right vocal cord palsy, a large conglomerate nodal mass in right level 4/6 and a solitary metastatic deposit in the L2 lumbar vertebra. Figure 1 demonstrates the pre-operative CT findings. It was determined after multidisciplinary team (MDT) discussion to proceed down a radical route and offer surgery to the neck with stereotactic ablative radiotherapy (SABR) to the spinal lesion.

Axial section of CT neck/thorax; red arrow highlights invasion of mediastinal mass into posterior trachea (A). Level IV lymph node compressing the right internal jugular vein (B)

Intraoperatively, the primary tumour was grossly invading the trachea, oesophagus, tracheoesophageal groove, internal jugular vein and thyrocervical trunk with obliteration of planes. Extensive dissection was performed, and a decision was made to “shave” off the tumour from the trachea and treat the residual disease with systemic treatment. During the dissection of left level 6, the signal was lost on the left recurrent laryngeal nerve. Subsequently, the patient failed extubation due to bilateral cord palsy and was re-intubated immediately in operating theatre. On the fifth postoperative day, he developed neck cellulitis, surgical emphysema and sepsis (Fig. 2). Wound exploration revealed an infective collection and a large defect in the cervical trachea with a sloughed wall with the endotracheal tube being exposed in the neck. Intraoperatively, there was bubbling and frank pus within the neck wound and patient was difficult to ventilate. When the endotracheal tube was pushed further, the bubbling stopped and the leak improved. This was suggestive of tracheal perforation on the right side around the level of the 4th ring. The tube was secured distally with the cuff positioned just above the carina and drainage with debridement was performed. Four days later, the wound was re-explored and on inspection a 180-degree tracheal defect was identified at very low level in the neck. Tissues were very friable and unhealthy and attempts of direct repair failed. Decision was made to insert corrugated drains and keep patient intubated until a further plan is decided after MDT discussion.

Post-operative CT scan on day 5 (axial section) demonstrates collections in the surgical bed (red arrow) (A). Fluid and gas locules within the retrosternal space (red arrow – panel B). Collection extending into the superior mediastinum (B)

In view of the bilateral cord palsy, residual tumour in relation to the cervical oesophagus and the damaged trachea, the MDT discussion advised laryngo-pharyngo-oesophagectomy, securing the airway, followed by oesophageal substitution. Surgery was performed four days later. The pharyngo-laryngectomy along with resection of damaged trachea and cervical oesophagus was performed, thus not only removed the dysfunctional larynx, but achieved tumour clearance. The manubrium with the attached clavicles, first and second ribs bilaterally were all excised to expose the middle mediastinum and viable distal third of the trachea. The distal third of viable trachea was mobilized, ensuring preservation of blood supply and was transposed slightly inferior and lateral to the innominate artery (Fig. 4). The right pedicled pectoralis major muscle flap was raised based on its thoracoacromial blood supply, the entire muscle with a skin island large enough to cover the defect and extend into the mediastinum was harvested for reconstruction of cervical and mediastinal defects. A circular stoma was fashioned in the middle part of the skin island and across the flap. The tracheal remnant was guided through this hole and the tracheal stump was sutured to the muscle and skin using interrupted 4/0 PDS sutures in two layers. The muscle layer of the flap was interposed between the trachea and the innominate artery. The flap was dropped into the mediastinum, ensuring no tension on the tracheal stoma (Fig. 3). Figure 4 shows a schematic drawing of tracheostomy secured to pectoralis muscle flap and its relations to innominate vessels. The cervical oesophagus was reconstructed using a free jejunal graft at the same sitting, but this failed due to poor circulation. A cervical oesophagostomy was performed, and patient was transferred back to intensive care mechanically ventilated. In order to minimise pressure trauma to the tracheal stoma, a modified adjustable length Bivona tracheostomy tube was secured using an Anchorfast strap stuck to the anterior chest wall, holding the tube in a vertical position. Patient movement/turning was only done as strictly necessary. This was maintained until the stoma had healed and the patient woken up, at which point a soft laryngectomy tube was place. Total parenteral nutrition was started on the first postoperative day and changed to enteral nutrition through the jejunostomy tube. The patient was weaned off ventilatory support and transferred to the ward one week later. The laryngo-oesophageal reconstruction was performed electively one month later, using an anterolateral fasciocutaneous free flap (ALT) with vascular reconstruction. Patient was extubated, stepped down to the ward in the second postoperative day and discharged home two weeks later. The patient was discharged home after two weeks. Figure 5 demonstrates the early post-operative appearances in the outpatient clinic four weeks following discharge. At 3 years post operatively, the patient has shown no sign of locoregional recurrence. He has returned to work and phonates well using a Servox electrolarynx. He manages a full diet.

Post-operative CT scan following AMT; A and B demonstrate the mediastinal tracheostomy, through the circular opening in the Pectoralis Major flap (red arrow). Sagittal sections (C and D) demonstrating tracheostomy tube entering distal trachea through the muscle flap. Axial section below level of the tracheostoma (panel E)

Schematic illustration of the mediastinal tracheostomy stump sutured to pectoralis muscle flap and its relation to innominate vessels. A Innominate artery (B) Left innominate vein. C Right innominate vein (D) Pectoralis muscle flap (E) Tracheostomy stump

Early post-operative appearances four weeks post discharge from hospital; AP view (A), left lateral view (B)