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Modification Of Endoscopic Montgomery T-Tube Insertion: The Challenge in Managing Difficult Airway

Author: Norazila Abdul Rahim

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Norazila Abdul Rahim¹, Masaany Mansor¹


We report a case of a 54-year-old lady with a history of subglottic stenosis Cotton-Myer grade 3 and tracheal stent insertion following dilatation of subglottic stenosis Cotton-Myer grade 3. She was electively admitted for removal of temporary tracheal stent (modified ETT) and Montgomery T- tube insertion.

Intra-operatively, the supraglottic and glottic area appeared grossly edematous while the subglottic area was occupied with granulation tissues that grew above the tracheal stent making it difficult to visualize the previous tracheal stent. After removal of the granulation tissue and the old tracheal stent, we also noted trachealis muscle prolapse anteroposteriorly obscuring the tracheal lumen almost entirely which made insertion of Montgomery T-tube rather difficult. 

We described our operative approach using HAVAS laryngoscope and a rigid bronchoscope size 7. A rigid bronchoscope size 7 was inserted through the mouth until the lower part of the stenotic segment to work as a ‘temporary stent’. This plays a major role to keep the airway patent while inserting Montgomery T-tube via tracheostoma. Once the T-tube was in the correct position, the rigid bronchoscope was then removed from the tracheal lumen. Post operatively, flexible nasopharyngolaryngoscopy (FNPLS) showed Montgomery T-tube remained in its position and patent.

There are various techniques related to insertion of Montgomery T-tube. We proposed this technique due to severe prolapse of the trachealis muscle anteroposteriorly obscuring the tracheal lumen. Our technique is safe and can be used as an alternative method if the Montgomery T-tube is unable to be placed by the usual endoscopic technique.

Keywords: Montgomery T tube; subglottic stenosis; trachealis muscle


  1. Department of Otorhinolaryngology, Faculty of Medicine Universiti Teknologi MARA(UiTM), Sg Buloh, Selangor, Malaysia; Hospital UiTM Puncak Alam, Selangor, Malaysia.



Correspondence to: 

Norazila Abdul Rahim, Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universiti Teknologi Mara, Sungai Buloh Campus, 47000 Sungai Buloh, Selangor, Malaysia. Email: [email protected]


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