A surgical conundrum: Managing primary tracheal adenoid cystic carcinoma with preservation of larynx

Title: A surgical conundrum: managing primary tracheal adenoid cystic carcinoma with preservation of larynx. Introduction: Tracheal tumors are extremely uncommon. The incidence of tracheal tumors is 0.09–0.2% out of which 10% are Adenoid cystic carcinoma. The origin of adenoid cystic carcinoma is from the submucosal glands of the tracheal tree. It is typically regarded as a low-grade malignancy with a favorable prognosis. Case Presentation: A 35 years old male patient came to Out Patient Department with chief complaints of change in voice since 6 months and stridor since 1 week. On Indirect laryngoscopy there was left sided vocal cord palsy with submucosal swelling in subglottic area compromising the airway. Contrast Enhanced Computed Tomography revealed a hyperintense lesion of about 5.5 cm craniocaudally in the posterolateral aspect of the subglottic trachea and inferior border of the cricoid pushing left thyroid lobe anterolaterally along with significant obstruction of the airway at the level of cricoid. An emergency tracheostomy was done at lower level to secure the airway. Flexible bronchoscopy showed a 1.5-2cm stenotic segment obstructing 50 to 75% of the airway in a subglottic region with left vocal cord palsy. A biopsy of the lesion took externally which came as an Adenoid Cystic Carcinoma. On Magnetic Resonance Imaging there was no involvement of the nerve or metastasis. Wide local excision of the lesion involving tracheal resection with cricotracheal anastomosis and Montgomery Tube insertion was done followed by chemoradiation. Montgomery tube was successfully removed and the patient satisfactorily decannulated. Conclusion: Adenoid cystic carcinoma should be considered as a differential diagnosis in patients with changes in voice and stridor. As adenoid cystic carcinoma is very slow-growing tumor so instead of being so radical a combined approach that gives a functional larynx and better quality of life should opt.