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‘Where did the tube go?’ A case of retropharyngeal submucosal false passage during nasal intubation
MJAFI-963; No. of Pages 3 medical journal armed forces india xxx (2018) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/mjafi
Case Report
'Where did the tube go?' A case of retropharyngeal submucosal false passage during nasal intubation Lt Col Bhargava V. Devarakonda a,*, Lt Col Yuvraj Issar b, Col Rakhee Goyal c, Kiranmai Vadapalli d a
Graded Specialist (Anaesthesiology), HQ IMTRAT, C/O 99 APO, Bhutan Graded Specialist (Oral & Maxillofacial Surgery), HQ IMTRAT, C/O 99 APO, Bhutan c Professor (Anaesthesiology & Critical Care), Army Hospital (Research & Referral), New Delhi, India d Assistant Professor (Physiology), Kamineni Institute of Medical Sciences, Narketpally, Telangana 508254, India b
article info Article history: Received 26 July 2017 Accepted 13 February 2018 Available online xxx Keywords: Intubation intratracheal Pharynx Wounds and Injuries Anaesthesia endotracheal
Introduction Nasotracheal intubation is a common method of endotracheal intubation for airway management, especially in patients undergoing repair of mandibular injuries requiring good access to oral structures. Various physical complications like epistaxis,1 damage to nasal turbinates,2 injury to nasopharyngeal mucosa,3 and inadvertent intracranial placement of tube4 during passage of endotracheal tube through nasal cavity have been reported in literature. We report a case of dissection of retropharyngeal submucosal plane during nasotracheal intubation with a flexometallic endotracheal intubation.
Case report A 22-year-old male patient suffered Fracture angle (Left) Parasymphysis (Right) of mandible after an accidental fall. He was posted for ORIF (Open reduction and rigid internal fixation). On evaluation, there was no history suggestive of traumatic brain injury as a result of the fall. There was no injury to any other body part. He did not report any comorbidity and had no known allergies to any medication. He underwent Tonsillectomy 10 years ago under general anaesthesia which was reported uneventful. On examination, body weight 51 kg; pulse 74 bpm; BP 118/68 mmHg; GCS-E4V5M6; pupillary size equal both sides with normal reaction to light. Systemic examination was unremarkable. Airway examination was unremarkable with no anticipated difficult airway. Patient was accepted for ORIF in ASA PS grade 1. General anaesthesia with nasal endotracheal intubation with flexometallic tube was the anaesthetic technique necessary for the procedure. Informed written consent was obtained. On the day of surgery, patient was placed supine and standard monitoring devices (ECG, NIBP, spO2) were applied. Inj Morphine 6 mg IV and Inj Glycopyrrolate 0.2 mg IV was administered. Xylometazoline drops 0.05% was administered in right nostril. Anaesthetic induction was carried out using Inj Propofol 120 mg. After confirming successful mask ventilation, Inj Vecuronium 6 mg IV was administered. Patient was ventilated via Bain's circuit with 100% oxygen for 3 min. A 'thermosoftened' lubricated flexometallic cuffed endotracheal
* Corresponding author. E-mail address: [email protected] (B.V. Devarakonda). https://doi.org/10.1016/j.mjafi.2018.02.002 0377-1237/© 2018 Published by Elsevier B.V. on behalf of Director General, Armed Forces Medical Services.
Please cite this article in press as: Devarakonda BV, et al. 'Where did the tube go?' A case of retropharyngeal submucosal false passage during nasal intubation, Med J Armed Forces India. (2018), https://doi.org/10.1016/j.mjafi.2018.02.002
MJAFI-963; No. of Pages 3
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medical journal armed forces india xxx (2018) xxx–xxx
Fig. 1 – Site of retopharyngeal submucosal tear seen posterolateral to the endotracheal tube. (Indicated by arrow).
tube (7.0 mm ID) was inserted into lubricated right nostril along the floor of the nasal cavity in the direction towards occipital protuberance. The tube with bevel facing the nasal septum was advanced blindly for about 7 cm without any difficulty through the nasal cavity. Laryngoscopy was performed. However, the endotracheal tube tip which was expected to be seen in oropharynx could not be located. There was evidence of local trauma in the form of blood in oropharynx. On suctioning the blood, it was noticed that there was submucosal swelling in posterior pharyngeal wall, at the junction of nasopharyx and oropharynx roughly similar to outline of the endotracheal tube (Fig. 1). On slight withdrawal of the tube outwards from nostril, the swelling disappeared instantly. The swelling reappeared on insertion of the tube. It was inferred that the endotracheal tube inserted nasally had made a blind submucosal false passage in the retropharyngeal region. The endotracheal tube was withdrawn from nostril completely and oropharynx examined to confirm no further bleeding. A gum elastic bougie was inserted through the right nostril carefully and slowly along the floor of nose. Bougie appeared in the oropharynx without entering the false passage. The bougie was advanced in the pharynx to enter the glottis and then endotracheal tube was railroaded over the bougie. Laryngoscopy showed Cormack Lehane grade 2 view and successful endotracheal intubation was performed. Bougie was withdrawn. Oropharynx was examined again to ensure there was no bleeding. The maxillofacial surgeon who was to operate upon the fracture mandible examined the oropharynx, identified the mucosal tear and sutured it using 3-0 Vicryl (Fig. 2). The ORIF procedure for Fracture Mandible was subsequently performed and completed uneventfully. The mucosal tear site was examined once again at the end of the surgery to ensure there was no bleeding, haematoma or swelling. Extubation of trachea was performed and patient monitored in ICU for 12 h for potential airway compromise. Postoperative recovery was uneventful. Patient was discharged on day 5 after surgery.
Fig. 2 – Retropharyngeal submucosal injury site after suturing.
Discussion Injuries to pharynx constitute 19% of all airway injuries during anaesthesia in a review of 4460 cases from ASA closed claims database.5 Retropharyngeal submucosal damage has been reported in literature.3 However, the consequences of such an event can be further complicated by application of positive pressure ventilation without confirmation of intratracheal position of endotracheal tube.6 Traumatic complications during nasotracheal intubation have been attributed to various factors like use of tube size larger than indicated, incorrect direction of bevel, excessive force during insertion, avoiding gentle manipulation of the tube during insertion, omitting use of topical vasoconstrictors and failure to detect loss of airflow from tube even after passing beyond turbinates.7 Various methods like use of 'thermosoftened' tubes,8 use of suction catheters9 or gum elastic bougie10 to act as guide for ETT have also been described in literature to avoid complications during nasotracheal intubation. In the present case, retropharyngeal submucosal passage of tube occurred in spite of avoiding all the potential risk factors. The authors attribute the past history of tonsillectomy and corresponding past surgical injury at the same site to be predisposing factors for the mucosal tear and creation of retropharyngeal submucosal false passage. Authors could not find any reports where pharyngeal mucosal tear has been attributed to old surgical injury. Hence, it would be safe to conclude that a preventive strategy to avoid traumatic complications during nasotracheal intubation involves combining risk factors mitigation and application of techniques using various adjuncts.
Conflicts of interest The authors have none to declare.
Please cite this article in press as: Devarakonda BV, et al. 'Where did the tube go?' A case of retropharyngeal submucosal false passage during nasal intubation, Med J Armed Forces India. (2018), https://doi.org/10.1016/j.mjafi.2018.02.002
MJAFI-963; No. of Pages 3 medical journal armed forces india xxx (2018) xxx–xxx
references
1. Chen YN, Chen JY, Hsu CS, Huang CT, So E. Recurrent epistaxis following nasotracheal intubation: a case report. Acta Anaesthesiol Sin. 1996;34:93–96. 2. Goyal VK, Solanki SL, Parekh AU, Gupta P. Complete airway obstruction with inferior turbinate vulsion after nasotracheal intubation. Saudi J Anaesth. 2016;10:114–115. 3. Krebs MJ, Sakai T. Retropharyngeal dissection during nasotracheal intubation: a rare complication and its management. J Clin Anesth. 2008;20:218–221. 4. Paul M, Dueck M, Kampe S, Petzke F, Ladra A. Intracranial placement of a nasotracheal tube after transnasal transsphenoidal surgery. Br J Anaesth. 2003;91:601–604.
5. Domino KB, Postner KL, Caplan RA, Cheney FW. Airway injury during anesthesia. Anesthesiology. 1999;91:1703–1711. 6. Peña MT, Aujla PK, Choi SS, Zalzal GH. Acute airway distress from endotracheal intubation injury in the pediatric aerodigestive tract. Otolaryngol Head Neck Surg. 2004;130: 575–578. 7. Prasanna D, Bhat S. Nasotracheal intubation: an overview. J Maxillofac Oral Surg. 2014;13:366–372. 8. Kim YC, Lee SH, Noh GJ, et al. Thermosoftening treatment of nasotracheal tube before intubation can reduce epistaxis and nasal damage. Anesth Analg. 2000;91:698–701. 9. Lee DS, Yang CI. Suction catheter-guided nasotracheal intubation. Anesthesiology. 1997;87:449–450. 10. Cossham PS. Nasotracheal tube placement over a bougie. Anaesthesia. 1997;52:184–185.
Please cite this article in press as: Devarakonda BV, et al. 'Where did the tube go?' A case of retropharyngeal submucosal false passage during nasal intubation, Med J Armed Forces India. (2018), https://doi.org/10.1016/j.mjafi.2018.02.002
3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/mjafi
Case Report
'Where did the tube go?' A case of retropharyngeal submucosal false passage during nasal intubation Lt Col Bhargava V. Devarakonda a,*, Lt Col Yuvraj Issar b, Col Rakhee Goyal c, Kiranmai Vadapalli d a
Graded Specialist (Anaesthesiology), HQ IMTRAT, C/O 99 APO, Bhutan Graded Specialist (Oral & Maxillofacial Surgery), HQ IMTRAT, C/O 99 APO, Bhutan c Professor (Anaesthesiology & Critical Care), Army Hospital (Research & Referral), New Delhi, India d Assistant Professor (Physiology), Kamineni Institute of Medical Sciences, Narketpally, Telangana 508254, India b
article info Article history: Received 26 July 2017 Accepted 13 February 2018 Available online xxx Keywords: Intubation intratracheal Pharynx Wounds and Injuries Anaesthesia endotracheal
Introduction Nasotracheal intubation is a common method of endotracheal intubation for airway management, especially in patients undergoing repair of mandibular injuries requiring good access to oral structures. Various physical complications like epistaxis,1 damage to nasal turbinates,2 injury to nasopharyngeal mucosa,3 and inadvertent intracranial placement of tube4 during passage of endotracheal tube through nasal cavity have been reported in literature. We report a case of dissection of retropharyngeal submucosal plane during nasotracheal intubation with a flexometallic endotracheal intubation.
Case report A 22-year-old male patient suffered Fracture angle (Left) Parasymphysis (Right) of mandible after an accidental fall. He was posted for ORIF (Open reduction and rigid internal fixation). On evaluation, there was no history suggestive of traumatic brain injury as a result of the fall. There was no injury to any other body part. He did not report any comorbidity and had no known allergies to any medication. He underwent Tonsillectomy 10 years ago under general anaesthesia which was reported uneventful. On examination, body weight 51 kg; pulse 74 bpm; BP 118/68 mmHg; GCS-E4V5M6; pupillary size equal both sides with normal reaction to light. Systemic examination was unremarkable. Airway examination was unremarkable with no anticipated difficult airway. Patient was accepted for ORIF in ASA PS grade 1. General anaesthesia with nasal endotracheal intubation with flexometallic tube was the anaesthetic technique necessary for the procedure. Informed written consent was obtained. On the day of surgery, patient was placed supine and standard monitoring devices (ECG, NIBP, spO2) were applied. Inj Morphine 6 mg IV and Inj Glycopyrrolate 0.2 mg IV was administered. Xylometazoline drops 0.05% was administered in right nostril. Anaesthetic induction was carried out using Inj Propofol 120 mg. After confirming successful mask ventilation, Inj Vecuronium 6 mg IV was administered. Patient was ventilated via Bain's circuit with 100% oxygen for 3 min. A 'thermosoftened' lubricated flexometallic cuffed endotracheal
* Corresponding author. E-mail address: [email protected] (B.V. Devarakonda). https://doi.org/10.1016/j.mjafi.2018.02.002 0377-1237/© 2018 Published by Elsevier B.V. on behalf of Director General, Armed Forces Medical Services.
Please cite this article in press as: Devarakonda BV, et al. 'Where did the tube go?' A case of retropharyngeal submucosal false passage during nasal intubation, Med J Armed Forces India. (2018), https://doi.org/10.1016/j.mjafi.2018.02.002
MJAFI-963; No. of Pages 3
2
medical journal armed forces india xxx (2018) xxx–xxx
Fig. 1 – Site of retopharyngeal submucosal tear seen posterolateral to the endotracheal tube. (Indicated by arrow).
tube (7.0 mm ID) was inserted into lubricated right nostril along the floor of the nasal cavity in the direction towards occipital protuberance. The tube with bevel facing the nasal septum was advanced blindly for about 7 cm without any difficulty through the nasal cavity. Laryngoscopy was performed. However, the endotracheal tube tip which was expected to be seen in oropharynx could not be located. There was evidence of local trauma in the form of blood in oropharynx. On suctioning the blood, it was noticed that there was submucosal swelling in posterior pharyngeal wall, at the junction of nasopharyx and oropharynx roughly similar to outline of the endotracheal tube (Fig. 1). On slight withdrawal of the tube outwards from nostril, the swelling disappeared instantly. The swelling reappeared on insertion of the tube. It was inferred that the endotracheal tube inserted nasally had made a blind submucosal false passage in the retropharyngeal region. The endotracheal tube was withdrawn from nostril completely and oropharynx examined to confirm no further bleeding. A gum elastic bougie was inserted through the right nostril carefully and slowly along the floor of nose. Bougie appeared in the oropharynx without entering the false passage. The bougie was advanced in the pharynx to enter the glottis and then endotracheal tube was railroaded over the bougie. Laryngoscopy showed Cormack Lehane grade 2 view and successful endotracheal intubation was performed. Bougie was withdrawn. Oropharynx was examined again to ensure there was no bleeding. The maxillofacial surgeon who was to operate upon the fracture mandible examined the oropharynx, identified the mucosal tear and sutured it using 3-0 Vicryl (Fig. 2). The ORIF procedure for Fracture Mandible was subsequently performed and completed uneventfully. The mucosal tear site was examined once again at the end of the surgery to ensure there was no bleeding, haematoma or swelling. Extubation of trachea was performed and patient monitored in ICU for 12 h for potential airway compromise. Postoperative recovery was uneventful. Patient was discharged on day 5 after surgery.
Fig. 2 – Retropharyngeal submucosal injury site after suturing.
Discussion Injuries to pharynx constitute 19% of all airway injuries during anaesthesia in a review of 4460 cases from ASA closed claims database.5 Retropharyngeal submucosal damage has been reported in literature.3 However, the consequences of such an event can be further complicated by application of positive pressure ventilation without confirmation of intratracheal position of endotracheal tube.6 Traumatic complications during nasotracheal intubation have been attributed to various factors like use of tube size larger than indicated, incorrect direction of bevel, excessive force during insertion, avoiding gentle manipulation of the tube during insertion, omitting use of topical vasoconstrictors and failure to detect loss of airflow from tube even after passing beyond turbinates.7 Various methods like use of 'thermosoftened' tubes,8 use of suction catheters9 or gum elastic bougie10 to act as guide for ETT have also been described in literature to avoid complications during nasotracheal intubation. In the present case, retropharyngeal submucosal passage of tube occurred in spite of avoiding all the potential risk factors. The authors attribute the past history of tonsillectomy and corresponding past surgical injury at the same site to be predisposing factors for the mucosal tear and creation of retropharyngeal submucosal false passage. Authors could not find any reports where pharyngeal mucosal tear has been attributed to old surgical injury. Hence, it would be safe to conclude that a preventive strategy to avoid traumatic complications during nasotracheal intubation involves combining risk factors mitigation and application of techniques using various adjuncts.
Conflicts of interest The authors have none to declare.
Please cite this article in press as: Devarakonda BV, et al. 'Where did the tube go?' A case of retropharyngeal submucosal false passage during nasal intubation, Med J Armed Forces India. (2018), https://doi.org/10.1016/j.mjafi.2018.02.002
MJAFI-963; No. of Pages 3 medical journal armed forces india xxx (2018) xxx–xxx
references
1. Chen YN, Chen JY, Hsu CS, Huang CT, So E. Recurrent epistaxis following nasotracheal intubation: a case report. Acta Anaesthesiol Sin. 1996;34:93–96. 2. Goyal VK, Solanki SL, Parekh AU, Gupta P. Complete airway obstruction with inferior turbinate vulsion after nasotracheal intubation. Saudi J Anaesth. 2016;10:114–115. 3. Krebs MJ, Sakai T. Retropharyngeal dissection during nasotracheal intubation: a rare complication and its management. J Clin Anesth. 2008;20:218–221. 4. Paul M, Dueck M, Kampe S, Petzke F, Ladra A. Intracranial placement of a nasotracheal tube after transnasal transsphenoidal surgery. Br J Anaesth. 2003;91:601–604.
5. Domino KB, Postner KL, Caplan RA, Cheney FW. Airway injury during anesthesia. Anesthesiology. 1999;91:1703–1711. 6. Peña MT, Aujla PK, Choi SS, Zalzal GH. Acute airway distress from endotracheal intubation injury in the pediatric aerodigestive tract. Otolaryngol Head Neck Surg. 2004;130: 575–578. 7. Prasanna D, Bhat S. Nasotracheal intubation: an overview. J Maxillofac Oral Surg. 2014;13:366–372. 8. Kim YC, Lee SH, Noh GJ, et al. Thermosoftening treatment of nasotracheal tube before intubation can reduce epistaxis and nasal damage. Anesth Analg. 2000;91:698–701. 9. Lee DS, Yang CI. Suction catheter-guided nasotracheal intubation. Anesthesiology. 1997;87:449–450. 10. Cossham PS. Nasotracheal tube placement over a bougie. Anaesthesia. 1997;52:184–185.
Please cite this article in press as: Devarakonda BV, et al. 'Where did the tube go?' A case of retropharyngeal submucosal false passage during nasal intubation, Med J Armed Forces India. (2018), https://doi.org/10.1016/j.mjafi.2018.02.002
3