When most healthcare professionals think of ECMO (Extracorporeal Membrane Oxygenation), they typically picture it as a critical life support system for patients with severe respiratory or cardiac failure. However, a fascinating new case report highlights how this powerful technology is finding novel applications in complex surgical scenarios, showcasing ECMO’s versatility beyond its traditional role.

From Challenge to Innovation

Published in the International Medical Case Reports Journal in July 2024, the case describes a 46-year-old man who developed what’s known as a “woody neck”—severe neck fibrosis resulting from multiple radiation treatments for tonsillar cancer. When facial swelling led to impending airway loss, the situation became critical and required emergency intubation with a nasotracheal tube.

 

To provide a definitive airway solution, a tracheostomy was needed, but the case proved far from straightforward. The patient had developed bilateral internal jugular vein occlusion, causing severe venous congestion in the neck tissues. This occlusion, combined with the radiation-induced fibrosis, made the surgical dissection extremely challenging. Despite multiple careful attempts at tracheal cannulation, the team was unable to successfully place the tracheostomy. Thus, the surgical team needed to think creatively about how to overcome these challenging conditions.

ECMO: Beyond Life Support

While cardiopulmonary bypass (CPB) had long been the standard approach for complex tracheal surgeries, particularly in pediatric cases, the surgical team in this case turned to ECMO instead. ECMO is an attractive alternative to CPB due to its reduced anticoagulation requirements, lessened inflammatory response, and ability to be maintained for longer periods if needed.

 

In this case, the initiation of ECMO support ultimately enabled successful tracheal cannulation after the previous attempt had failed. By providing stable oxygenation independent of the airway, it created a controlled environment that allowed the surgeons to complete the tracheostomy. After an uneventful recovery, the patient was discharged home two weeks later.

Growing Evidence for ECMO in Airway Surgery

ECMO has proven invaluable in other challenging airway scenarios beyond complex tracheostomies. One literature review found that ECMO played a crucial role in maintaining oxygenation for 9 out of 14 cancer patients with airway emergencies. In addition, ECMO has successfully facilitated procedures for conditions such as obstructing tumors, severe tracheal stenosis, and mediastinal masses.

 

These expanding applications highlight how ECMO has evolved far beyond its origins as a rescue therapy for severe heart and lung failure. What began as a lifesaving support system has transformed into an enabling technology that opens new possibilities in complex airway surgery. As surgical teams gain more experience and comfort with ECMO support, we’re likely to see further innovations in how this versatile technology can be deployed to tackle previously formidable surgical challenges.