Retropharyngeal dissection during nasotracheal intubation: a rare complication and its management

Journal of Clinical Anesthesia (2008) 20, 218–221

Case report

Retropharyngeal dissection during nasotracheal intubation: a rare complication and its management Matthew J. Krebs MD (Resident), Tetsuro Sakai MD, PhD (Assistant Professor)⁎ Department of Anesthesiology, University of Pittsburgh, UPMC Montefiore, Pittsburgh, PA 15213, USA Received 19 April 2007; revised 9 August 2007; accepted 1 September 2007

Keywords: Intubation, intratracheal/ adverse effects; Nasotracheal intubation; Pharynx/injuries; Retropharyngeal dissection

Abstract Nasotracheal intubation carries potential risks, including nasal bleeding and other structural damage. We report a retropharyngeal dissection (or a false passage in the nasopharyngeal mucosa) during attempted nasotracheal intubation of a 54-year-old woman undergoing lower jaw reconstruction. © 2008 Elsevier Inc. All rights reserved.

1. Introduction Nasotracheal intubation is a common procedure performed in the operating room (OR), especially in patients undergoing oromaxillary surgery. Nasotracheal intubation, however, has a greater potential for trauma to the nasopharyngeal mucosa than does orotracheal intubation. We report another complication, in which the tip of the endotracheal tube (ETT) perforated the nasopharyngeal mucosa and dissected the retropharyngeal mucosa to the right supratonsiller level.

2. Case report A 54-year-old, 163-cm, 95-kg woman presented with bilateral mandibular ossifying fibromas. Excision of the right-sided lesion, which compromised the shape and

⁎ Corresponding author. Department of Anesthesiology, UPMC Montefore, Pittsburgh, PA 15213, USA. Tel.: +1 412 648 6943; fax: +1 412 648 6014. E-mail address: [email protected] (T. Sakai). 0952-8180/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2007.09.021

strength of the mandible, reconstruction of the mandible with a titanium plate, and bone grafting were scheduled. The patient was otherwise healthy. Airway examination showed a Mallampati class II airway and patency of both nasal passages. General anesthesia with nasotracheal intubation using a nasal RAE tracheal tube (Mallinckrodt Medical, Athlone, Ireland) was planned. Oxymetazoline nasal spray (Afrin, Schering-Plough HealthCare Products, Inc, Kenilworth, NJ) was applied to both nostrils preoperatively. General anesthesia was induced with fentanyl 0.15 mg, propofol 200 mg, rocuronium 5 mg, and succinylcholine 160 mg intravenously. The left nasal passage was lubricated with direct application of 3 mL of Surgilube (Fougera Inc, Melville, NY). Insertion of a size 7.0 nasal RAE ETT was met with resistance. The right nasal passage was lubricated in the same manner, and the nasotracheal tube was blindly inserted 7 cm into the nasopharyngeal cavity without resistance. However, during the subsequent direct laryngoscopy, we could not identify the tip of the nasotracheal tube in the oropharynx. Instead, a longitudinal submucosal bulging in the posterolateral wall of the pharynx was noticed on the right side of the oropharyngeal cavity (Fig. 1). Digital palpation of the bulging confirmed that the tip of the nasal RAE tube made a false passage into the nasopharyngeal submucosa. The diagnosis of retropharyngeal dissection was

Retropharyngeal dissection during nasal intubation

219 The patient recovered without incident overnight and was transferred to a floor on the following day. On the second postoperative day, she was discharged home with a one-week course of oral clindamycin 150 mg four times per day. Her outpatient follow-up one week after the discharge was unremarkable.

3. Discussion

Fig. 1 A diagram of the intraoral finding of false passage into the nasopharyngeal mucosa. Submucosal bulging in the right posterolateral wall of the pharynx was noted (arrow). The false passage of a nasotracheal tube was confirmed by digital palpation of the bulging.

made. The nasotracheal tube was removed, and a standard orotracheal tube was inserted without difficulty. Immediately after the orotracheal intubation, an otolaryngology specialist was consulted to evaluate the retropharyngeal dissection. Endoscopic examination of the nasal cavity and the nasopharynx showed a less than 1 cm laceration of the mucosa near the orifice of the right Eustachian tube. No active bleeding or hematoma along the tract of the dissection was identified. External neck examination did not show any crepitus or air tracking within the prevertebral space or other fascial spaces. The right-sided nasopharyngeal cavity was packed with sterile gauze for prophylactic tamponade. The planned surgery was subsequently started. Anesthesia was maintained with sevoflurane and fentanyl. The patient underwent uneventful resection and curettage of the right mandibular lesion and exploration of the left lesion. All vital signs were stable during the surgery. The tracheal tube was removed at the end of the procedure in the OR, and the patient was brought to the postoperative care unit in stable condition. Because of the retropharyngeal dissection, the patient was admitted to the intensive care unit (ICU) for observation of her airway for possible delayed hematoma formation. A computed tomography (CT) in the neck was performed on the day of surgery to further assess the damage in the nasopharyngeal region; no hematoma or airway edema was noted. The patient received clindamycin 600 mg IV every 6 hours for the increased infection risk.

Nasotracheal intubation is often requested by surgeons for patients undergoing maxillofacial surgery. An orotracheal tube may interfere with surgical exposure during such procedures, and has an increased risk of dislodgement during surgery. In addition, orotracheal tubes should be avoided if postoperative intraoral maxillary fixation of the mandible is necessary. Yet nasotracheal intubation is not without risks. Epistaxis is the most frequent complication, with an incidence ranging from 10% to 80% [1-4]. Other complications include impingement of the ETT in the subglottic region, further hindering advancement after passing the glottis; sinusitis [5,6]; bacteremia [7]; and dislodgement of the adenoids [8]. Less common complications include unilateral nasal obstruction related to partial avulsion of the middle turbinate [9,10]. In addition, pharyngoesophageal perforation [11] and inadvertent intracranial placement of a nasotracheal tube [12] have been documented. Our case presents a healthy 54-year-old woman for resection of a right mandibular lesion. During the attempted nasotracheal intubation, a nasal RAE tube was inserted through the right nostril, but the tip failed to appear in the pharynx. The complication, retropharyngeal dissection or nasopharyngeal false passage, was quickly diagnosed by digital palpation of the bulging of the mucosa. This complication, scarcely reported during a blind nasal intubation in an emergency department [13] and in an OR [14-16], also has been rarely reported in a nasal tracheal intubation assisted with a direct laryngoscopy [17,18]. Chait and Poulton [17] reported a 33-year-old woman who had retropharyngeal dissection during attempted nasotracheal intubation, which was quickly diagnosed during a successive direct laryngoscopy and digital palpation. The patient had a small amount of epistaxis, which spontaneously stopped. Penicillin was initiated and continued for 5 days postoperatively. No further morbidity was reported. Recently, Ghaffari [18] reported a 7-year-old girl, in whom the posterior nasopharyngeal mucosa was penetrated by a nasal tube. In this case, an uncuffed nasal tube was forcefully inserted by the surgeon through the right nostril. Interestingly, direct laryngoscopy afterward did not show the perforation and the intubation was completed. During the scheduled tonsillectomy, the surgeon noticed that the nasotracheal tube pierced the posterior pharyngeal mucosa and then reentered the back of the mouth. It was thought

220 that the mucosal surface of the oral part of the pharynx was detached by the extreme force used in the insertion of the nasotracheal tube. After removal of the ETT, another ETT was successfully placed. No follow-up of the patient's postoperative course was documented [18]. Prompt recognition of a retropharyngeal dissection by direct laryngoscopy is vital to minimize damage. If the retropharyngeal dissection goes unrecognized, especially during a blind nasotracheal intubation, additional forceful insertion of the nasotracheal tube or attempt to ventilate via the tube may cause further tearing of the submucosa, leading to further dissection of the tissues [16], bleeding, hematoma formation, and compromised airway patency. Dissection of the retropharyngeal tissue also may result in retropharyngeal abscess, which can be a life-threatening complication [13]. Once the diagnosis is made, removing the ETT and securing the airway through alternative route are recommended. We consulted an otolaryngology specialist before the scheduled surgery, and endoscopic assessment of the injured nasopharynx showed no active bleeding or hematoma formation. The timing of removal of the ETT is also important. If there are any concerns of bony injury, deep structure injury, significant ongoing bleeding, or existing coagulopathy, a CT scan before extubation should be elected. In our case, intraoperative endoscopic findings and the patient's stable condition throughout the surgery allowed us to remove the ETT at the end of the operation. Postoperatively, the risk of late hematoma formation or tissue swelling due to the primary submucosal injury is possible. We performed a head and neck CT scan postoperatively and admitted the patient to an ICU overnight, although her condition immediately after the surgery was stable. Antibiotic prophylaxis was also prescribed to cover intranasal bacterial flora. Clindamycin was chosen. A broad-spectrum antibiotic is also recommended for this complication [4]. The postoperative follow-up is also important to detect any sign of retropharyngeal abscess. One must avoid excessive force when placing a nasotracheal tube so as to decrease the chances of a pharyngeal dissection. Thermo-softening treatment of a nasotracheal tube with warm saline before intubation effectively reduces epistaxis and nasal damage [19,20]. A recent study showed that use of a curve-tipped suction catheter to guide nasotracheal intubation resulted in increased success as well as a substantial decrease in the frequency and severity of epistaxis [21]. Choosing the right nostril for nasotracheal intubation when patency appears equal on both sides of the nose has been suggested [22]. The tracheal tube is designed such that the bevel is left-facing, favoring advancement of the tube along the nasal septum without piercing it. However, a recent study reported that no significant differences in intubation success or complication risk exist between either nostril [23]. The use of a flexible fiberoptic scope as an aid to nasotracheal intubation theoretically should minimize the chance of retropharyngeal

M.J. Krebs, T. Sakai dissection or other nasopharyngeal injuries due to “direct” visualization of the passage. A rare complication of retropharyngeal dissection during nasotracheal intubation is reported. Early recognition of the complication, immediate endoscopic assessment of the injury, careful follow-up of the patient's airway using imaging studies, observation of the patient in the ICU, and prophylactic antibiotic treatment are all recommended.

Acknowledgment The authors thank Padraic F. Driscoll (Media Services Developer, Physician Services Division, University of Pittsburgh Medical Center, Pittsburgh, PA) for his professional assistance with the drawing in Fig. 1 and Dr. Karen E. Schoedel (Assistant Professor, Department of Pathology, University of Pittsburgh Medical Center) for the complete translation of reference 14.

References [1] Piepho T, Thierbach A, Werner C. Nasotracheal intubation: look before you leap. Br J Anaesth 2005;94:859-60. [2] Enk D, Palmes AM, Van Aken H, Westphal M. Nasotracheal intubation: a simple and effective technique to reduce nasopharyngeal trauma and tube contamination. Anesth Analg 2002;95:1432-6. [3] Kihara S, Komatsuzaki T, Brimacombe JR, Yaguchi Y, Taguchi N, Watanabe S. A silicone-based wire-reinforced tracheal tube with a hemispherical bevel reduces nasal morbidity for nasotracheal intubation. Anesth Analg 2003;97:1488-91. [4] Hall CE, Shutt LE. Nasotracheal intubation for head and neck surgery. Anaesthesia 2003;58:249-56. [5] Holzapfel L, Chastang C, Demingeon G, Bohe J, Piralla B, Coupry A. A randomized study assessing the systematic search for maxillary sinusitis in nasotracheally mechanically ventilated patients. Influence of nosocomial maxillary sinusitis on the occurrence of ventilatorassociated pneumonia. Am J Respir Crit Care Med 1999;159:695-701. [6] Hansen M, Poulsen MR, Bendixen DK, Hartmann-Andersen F. Incidence of sinusitis in patients with nasotracheal intubation. Br J Anaesth 1988;61:231-2. [7] Onçağ O, Cökmez B, Aydemir S, Balcioglu T. Investigation of bacteremia following nasotracheal intubation. Paediatr Anaesth 2005; 15:194-8. [8] Ng SY, Yew WS. Nasotracheal tube occlusion from adenoid trauma. Anaesth Intensive Care 2006;34:829-30. [9] Williams AR, Burt N, Warren T. Accidental middle turbinectomy: a complication of nasal intubation. Anesthesiology 1999;90:1782-4. [10] Patiar S, Ho EC, Herdman RC. Partial middle turbinectomy by nasotracheal intubation. Ear Nose Throat J 2006;85:380-3. [11] Tartell PB, Hoover LA, Friduss ME, Zuckerbraun L. Pharyngoesophageal intubation injuries: three case reports. Am J Otolaryngol 1990; 11:256-60. [12] Paul M, Dueck M, Kampe S, Petzke F, Ladra A. Intracranial placement of a nasotracheal tube after transnasal trans-sphenoidal surgery. Br J Anaesth 2003;91:601-4. [13] Tintinalli JE, Claffey J. Complications of nasotracheal intubation. Ann Emerg Med 1981;10:142-4. [14] Loers FJ, Lindau B. Retropharyngeal dissection, a rare complication of nasal intubation. Anaesthesist 1975;24:545-6.

Retropharyngeal dissection during nasal intubation [15] Landess WW. Retropharyngeal dissection: a rare complication of nasotracheal intubation revisited–a case report. AANA J 1994;62:273-7. [16] Pena MT, Aujla PK, Choi SS, Zalzal GH. Acute airway distress from endotracheal intubation injury in the pediatric aerodigestive tract. Otolaryngol Head Neck Surg 2004;130:575-8. [17] Chait DH, Poulton TJ. Case report: retropharyngeal perforation, a complication of nasotracheal intubation. Nebr Med J 1984;69:68-9. [18] Ghaffari S. Forceful insertion of nasal tube may pierce the posterior nasopharyngeal mucosa. Paediatr Anaesth 2006;16:997. [19] Kim YC, Lee SH, Noh GJ, et al. Thermosoftening treatment of the nasotracheal tube before intubation can reduce epistaxis and nasal damage. Anesth Analg 2000;91:698-701.

221 [20] Lu PP, Liu HP, Shyr MH, et al. Softened endotracheal tube reduces the incidence and severity of epistaxis following nasotracheal intubation. Acta Anaesthesiol Sin 1998;36:193-7. [21] Morimoto Y, Sugimura M, Hirose Y, Taki K, Niwa H. Nasotracheal intubation under curve-tipped suction catheter guidance reduces epistaxis. Can J Anaesth 2006;53:295-8. [22] Fell D. The practical conduct of anaesthesia. In: Aitkenhead AR, Rowbotham DJ, Smith G, editors. Textbook of Anaesthesia. 4th edn. Edinburgh: Churchill Livingstone; 2001. p. 467. [23] Coe TR, Human M. The peri-operative complications of nasal intubation: a comparison of nostril side. Anaesthesia 2001;56: 447-50.