Ice cream cone sign: reversible ballooning of the trachea due to tracheostomy tube cuff overinflation Ashutosh Sachdeva, 1 Edward M Pickering, 2 Robert M Reed, 2 Carl B Shanholtz 1 1 Department of Pulmonary and Critical Care, University of Maryland, Baltimore, Maryland, USA 2 Department of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, Maryland, USA Correspondence to Dr Robert M Reed, rreed@medicine.umaryland.edu Accepted 17 April 2016 To cite: Sachdeva A, Pickering EM, Reed RM, et al. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/bcr-2016- 214625 DESCRIPTION A woman in her 80s with ventilator-dependent respiratory failure due to severe cardiomyopathy and critical illness myopathy was transferred to our hospital after experiencing recurrent episodes of ventricular fibrillation cardiac arrest requiring car- diopulmonary resuscitation. On arrival, there was a significant air leak despite tracheostomy tube (TT) cuff pressures of 50 cm H 2 O (normal <25 cm H 2 O). Chest radiography revealed what we term the ‘ice cream cone sign’ ( figure 1 and video 1), consistent with proximal trachea dilation from cuff overinflation. Bronchoscopy demon- strated tracheomegaly ( figure 2) at the cuff site, with a normal calibre distal trachea. TT distal end was not coaxial with the tracheal lumen and pointed posteriorly. The TT was exchanged for a longer cuffed TT with the distal end bypassing the ballooned segment and coaxial to the tracheal lumen. The air leak resolved with this intervention Figure 1 Ice cream cone sign with ballooning of proximal trachea. Video 1 Ice cream cone sign with ballooning of proximal trachea. Figure 2 Tracheostomy tube positioned improperly posteriorly. Arrows indicate area of malacia and dilated tracheal segment. Sachdeva A, et al. BMJ Case Rep 2016. doi:10.1136/bcr-2016-214625 1 Images in … on 29 May 2020 by guest. Protected by copyright. http://casereports.bmj.com/ BMJ Case Reports: first published as 10.1136/bcr-2016-214625 on 4 May 2016. Downloaded from