Endotracheal tube mal-insertion via Zenker’s diverticulum to trachea

An 86-year-old woman with chronic respiratory failure was under endotracheal tube insertion and mechanical ventilator support for 2 months due to previous intra-cranial hemorrhage. She presented with difficult nasogastric (NG) tube insertion after changing endotracheal tube and was transferred to our emergency room. The initial vital signs were blood pressure: 136/85 mmHg, heart rate: 100 bpm, respiratory rate: 20 cpm, body temperature: 36.5o c, and SpO2 : 100% under ventilator support, and stupor consciousness was remained as usual. The physical examination showed bilateral clear breath sound. We tried the NG tube insertion again but in vain; therefore, the esophagogastroduodenoscopy (EGD) was performed for NG tube insertion and revealed malposition of the endotracheal tube over upper esophagus and Zenker's diverticulum with ulcerations (Panel A). Endotracheal tube was inserted to the esophagus, via the Zenker's diverticulum, and then to the trachea. The neck CT confirmed the diagnosis (Panel B). After endotracheal tube replacement via bronchoscopy and supportive care with antibiotics treatment, the patient was discharged after admission for two weeks.