Authors: Yano et al.
Cureus 17(11): e96927, November 15, 2025. DOI: 10.7759/cureus.96927
Summary
This case report describes a 75-year-old man with progressive dyspnea caused by diffuse idiopathic skeletal hyperostosis (DISH) at the thoracic inlet. Severe bony overgrowth anteriorly and posteriorly created a fixed, narrowed space compressing the trachea to an estimated 5 mm diameter. Because both conventional intubation and tracheostomy were unsafe, the team used veno-venous extracorporeal membrane oxygenation (VV-ECMO) to maintain oxygenation while securing the airway.
VV-ECMO was initiated while the patient was awake. After induction with fentanyl, remifentanil, and propofol, a laryngeal mask airway was placed to maintain ventilation. A vertical sternotomy relieved anterior compression, allowing successful endotracheal intubation. ECMO was discontinued shortly thereafter. Osteophytes were resected, blood loss was minimal, and no intraoperative anticoagulation was used due to bleeding risk.
The patient remained intubated postoperatively due to anticipated airway edema and was extubated on postoperative day 2. Dyspnea improved significantly, and postoperative pulmonary function showed marked improvement in FEV₁%. Follow-up CT confirmed resolution of most of the bony compression.
This case highlights the effectiveness of short-term VV-ECMO as a bridge to airway control in patients with extreme tracheal obstruction from DISH at the thoracic inlet. The authors note that conventional surgical airway techniques would not bypass the obstruction, making ECMO a critical tool in such rare anatomic scenarios.
What You Should Know
• DISH can rarely cause critical tracheal obstruction, particularly when ossification occurs between the vertebral bodies and sternum.
• In this case, tracheal diameter was only ~5 mm, making both intubation and tracheostomy unsafe.
• VV-ECMO allowed safe induction, ventilation, and decompression before intubation.
• ECMO was performed without anticoagulation for a short duration to minimize bleeding risk.
• Postoperative lung function significantly improved after decompression and osteophyte removal.
• VV-ECMO is a viable strategy in extraordinary airway obstructions located deep at the thoracic inlet.
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