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Unusual nasoendotracheal tube damage during Le Fort I osteotomy
Unusual nasoendotrachealtube damage during Le Fort I osteotomy
Douglas J. Valentine 1, Leonard B. Kaban 2 1Chief Resident, Department of Oral and Maxillofacial Surgery, 2Professor and Chairman, Department of Oral and Maxillofacial Surgery
Case report D. J. Valentine, L. B. Kaban: Unusual nasoendotracheal tube damage during Le Fort I osteotomy. Case report. Int. J. Oral Maxillofac. Surg. 1992; 21." 333-334. © Munksgaard 1992
Abstract. An unusual case of endotracheal tube damage during Le Fort I osteotomy is presented. A minor change in design of the tube might prevent similar complications.
Endotracheal tube damage during oral and maxillofacial surgery procedures is well documented in the literature 14. This most c o m m o n l y occurs in maxillary orthognathic surgery with nasal intubation. THYNE et al. recently reported a case in which the pilot and main tubes were inadvertently severed during Le Fort I osteotomy 7. The authors concluded that the tubes were cut by an osteotome during pterygomaxillary disjunction. We have recently experienced a similar, although slightly different, complication during a Le Fort I osteotomy. To our knowledge, this is the first reported case in which a pilot tube has been cut and simultaneously sealed off by plastic fragments and blood clot.
Case report A 34-year-old woman was to undergo a Le Fort I and bilateral vertical ramus osteotomies for correction of vertical maxillary excess and mandibular prognathism. General anesthesia was employed and the airway was securedwith a size 6.5 Mallinckrodt Nasal
Fig. 1. Photograph showing inflated cuff of nasoendotracheal tube immediately following extubation.
RAE ® (Mallinckrodt ®, Glens Fall, New York) tube in the right naris. Shortly after separation of the nasal septum from the hard palate, an air leak was noted around the oropharyngeal pack. The balloon to the tube cuff remained inflated, and it was assumed that only the endotracheal tube itself had been perforated. The oropharyngeal pack was replaced with a larger one, at which time the leak was arrested. There was no difficulty in maintaining ventilation; therefore, the operation was completed without further delay. During emergence from anesthesia, attempts at inflating or deflating the cuff through the pilot were unsuccessful. It was thought that the cuff was probably still inflated at this time. This was confirmed by palpation and a postoperative chest radiograph. An attempt was then made to deflate the cuff by cutting off the pilot tube balloon; this had no apparent effect. The nasoendotracheal tube was left in place for another 2 h to allow the balloon partially to deflate by diffusion of gases. At this time the tube was removed without incident. Immediate examination revealed that the cuff was inflated (Fig. 1). There was a small cut 4 cm beyond the bend of the RAE ® tube. The damage was located exactly on the in-
Fig. 2. Close-up view of area of damage. Pilot tube is occluded in both directions with fragments of plastic and blood clot.
Key words: endotracheal tube damage; Le Fort I osteotomy. Accepted for publication 23 July 1992
ferior aspect of the endotracheal tube and directly through the pilot (Fig. 2). A small perforation into the main tube was also noted at the same location. Closer examination revealed that the cut had resulted in occlusion of the pilot tube proximally and distally by the disfigured plastic and blood clot. This explained why the cuff had remained inflated and also why the balloon could neither be inflated nor be deflated with a syringe. The patient had an uneventful postoperative course and recovery.
Discussion In this case, endotracheal tube damage resulted during the osteotomy to separate the nasal septum from the hard palate. Our conclusion is based on the timing of occurrence of the leak and the location of the cut in the endotracheal tube. This complication is well known and several such cases have been reported in the last 15 years 2,3,4,7,8. Inadequate ventilation, delay of surgery, airway compromise if the tube requires immediate intraoperative replacement, and difficulty in the eventual removal of the tube all produce potential intraoperative risks to the patient. The operating team is also at risk from unnecessary exposure to anesthetic gases. The nasal R A E ® endotracheal tube pilot channel runs along the inferior surface. It has been suggested by MOSBY et al. 3 that this small tube would be better located along the superior wall. This would afford it the most protection from our instrumentation, and should have no deleterious effects on the functioning of the balloon and cuff itself. This change in design would not prevent
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d a m a g e to the m a i n t u b e b u t would prevent a n event such as t h a t r e p o r t e d in this paper. W h e n the p a t i e n t is extubated with an inflated cuff, there is risk o f d a m a g e to the trachea, vocal cords, or n a s o p h a r y n x 2. This case is r e p o r t e d as a n u n u s u a l variant o f e n d o t r a c h e a l tube injury, resulting in a confusing inability to inflate or deflate the cuff. This is a rare complication; however, a m i n o r c h a n g e in the tube design could p r e v e n t similar complications f r o m occurring in the future. References 1. BAKER C, KORA S, ABADIR A. Management of a perforated endotracheal tube
during orthognathic surgery. Anesth Prog 1988: 35:158 9. 2. FAGRAEUSL, ANO~LILLO J, DOLAN E. A serious anesthetic hazard during orthognathic surgery. Anesth Analg 1980: 59: 150-3. 3. MOSBYEL, MESSERE J, NEALISMF, GOLDEN DP. Intraoperative damage to nasotracheal tubes during maxillary surgery: report of cases. J Oral Surg 1978: 36: 9634. 4. PAGAR DM, KUPPEMANAW, STERN M. Cutting of nasoendotracheal tube: an unusual complication of maxillary osteotomies. J Oral Surg 1978: 36:314 15. 5. PESKIN RM, SACHS SA. Intraoperative management of a partially severed endotracheal tube during orthognathic surgery. Anesth Prog 1986: 33: 247-51. 6. SCHWARTZ L, SORDILL W, LIEBERS R,
SCHWABW. Difficulty in removal of accidentally cut endotracheal tube. J Oral Maxillofac Surg 1982: 40: 518-19. 7. TItYNE GN, FERGUSONJW, PILDITCH FD. Endotracheal tube damage during orthognathic surgery. Int J Oral Maxillofac Surg 1992: 21: 80. 8. TSUEDA K, CAREY W J, GONTY AA, BOSOMWORTH PB. Hazards to anesthetic equipment during maxillary oste0tomy: report of cases. J Oral Surg 1977: 35: 47.
Address: Dr L. B. Kaban Department of Oral and Maxillofacial Surgery University of California, San Francisco San Francisco, CA 94143-0440 USA
Douglas J. Valentine 1, Leonard B. Kaban 2 1Chief Resident, Department of Oral and Maxillofacial Surgery, 2Professor and Chairman, Department of Oral and Maxillofacial Surgery
Case report D. J. Valentine, L. B. Kaban: Unusual nasoendotracheal tube damage during Le Fort I osteotomy. Case report. Int. J. Oral Maxillofac. Surg. 1992; 21." 333-334. © Munksgaard 1992
Abstract. An unusual case of endotracheal tube damage during Le Fort I osteotomy is presented. A minor change in design of the tube might prevent similar complications.
Endotracheal tube damage during oral and maxillofacial surgery procedures is well documented in the literature 14. This most c o m m o n l y occurs in maxillary orthognathic surgery with nasal intubation. THYNE et al. recently reported a case in which the pilot and main tubes were inadvertently severed during Le Fort I osteotomy 7. The authors concluded that the tubes were cut by an osteotome during pterygomaxillary disjunction. We have recently experienced a similar, although slightly different, complication during a Le Fort I osteotomy. To our knowledge, this is the first reported case in which a pilot tube has been cut and simultaneously sealed off by plastic fragments and blood clot.
Case report A 34-year-old woman was to undergo a Le Fort I and bilateral vertical ramus osteotomies for correction of vertical maxillary excess and mandibular prognathism. General anesthesia was employed and the airway was securedwith a size 6.5 Mallinckrodt Nasal
Fig. 1. Photograph showing inflated cuff of nasoendotracheal tube immediately following extubation.
RAE ® (Mallinckrodt ®, Glens Fall, New York) tube in the right naris. Shortly after separation of the nasal septum from the hard palate, an air leak was noted around the oropharyngeal pack. The balloon to the tube cuff remained inflated, and it was assumed that only the endotracheal tube itself had been perforated. The oropharyngeal pack was replaced with a larger one, at which time the leak was arrested. There was no difficulty in maintaining ventilation; therefore, the operation was completed without further delay. During emergence from anesthesia, attempts at inflating or deflating the cuff through the pilot were unsuccessful. It was thought that the cuff was probably still inflated at this time. This was confirmed by palpation and a postoperative chest radiograph. An attempt was then made to deflate the cuff by cutting off the pilot tube balloon; this had no apparent effect. The nasoendotracheal tube was left in place for another 2 h to allow the balloon partially to deflate by diffusion of gases. At this time the tube was removed without incident. Immediate examination revealed that the cuff was inflated (Fig. 1). There was a small cut 4 cm beyond the bend of the RAE ® tube. The damage was located exactly on the in-
Fig. 2. Close-up view of area of damage. Pilot tube is occluded in both directions with fragments of plastic and blood clot.
Key words: endotracheal tube damage; Le Fort I osteotomy. Accepted for publication 23 July 1992
ferior aspect of the endotracheal tube and directly through the pilot (Fig. 2). A small perforation into the main tube was also noted at the same location. Closer examination revealed that the cut had resulted in occlusion of the pilot tube proximally and distally by the disfigured plastic and blood clot. This explained why the cuff had remained inflated and also why the balloon could neither be inflated nor be deflated with a syringe. The patient had an uneventful postoperative course and recovery.
Discussion In this case, endotracheal tube damage resulted during the osteotomy to separate the nasal septum from the hard palate. Our conclusion is based on the timing of occurrence of the leak and the location of the cut in the endotracheal tube. This complication is well known and several such cases have been reported in the last 15 years 2,3,4,7,8. Inadequate ventilation, delay of surgery, airway compromise if the tube requires immediate intraoperative replacement, and difficulty in the eventual removal of the tube all produce potential intraoperative risks to the patient. The operating team is also at risk from unnecessary exposure to anesthetic gases. The nasal R A E ® endotracheal tube pilot channel runs along the inferior surface. It has been suggested by MOSBY et al. 3 that this small tube would be better located along the superior wall. This would afford it the most protection from our instrumentation, and should have no deleterious effects on the functioning of the balloon and cuff itself. This change in design would not prevent
334
Valentine and Kaban
d a m a g e to the m a i n t u b e b u t would prevent a n event such as t h a t r e p o r t e d in this paper. W h e n the p a t i e n t is extubated with an inflated cuff, there is risk o f d a m a g e to the trachea, vocal cords, or n a s o p h a r y n x 2. This case is r e p o r t e d as a n u n u s u a l variant o f e n d o t r a c h e a l tube injury, resulting in a confusing inability to inflate or deflate the cuff. This is a rare complication; however, a m i n o r c h a n g e in the tube design could p r e v e n t similar complications f r o m occurring in the future. References 1. BAKER C, KORA S, ABADIR A. Management of a perforated endotracheal tube
during orthognathic surgery. Anesth Prog 1988: 35:158 9. 2. FAGRAEUSL, ANO~LILLO J, DOLAN E. A serious anesthetic hazard during orthognathic surgery. Anesth Analg 1980: 59: 150-3. 3. MOSBYEL, MESSERE J, NEALISMF, GOLDEN DP. Intraoperative damage to nasotracheal tubes during maxillary surgery: report of cases. J Oral Surg 1978: 36: 9634. 4. PAGAR DM, KUPPEMANAW, STERN M. Cutting of nasoendotracheal tube: an unusual complication of maxillary osteotomies. J Oral Surg 1978: 36:314 15. 5. PESKIN RM, SACHS SA. Intraoperative management of a partially severed endotracheal tube during orthognathic surgery. Anesth Prog 1986: 33: 247-51. 6. SCHWARTZ L, SORDILL W, LIEBERS R,
SCHWABW. Difficulty in removal of accidentally cut endotracheal tube. J Oral Maxillofac Surg 1982: 40: 518-19. 7. TItYNE GN, FERGUSONJW, PILDITCH FD. Endotracheal tube damage during orthognathic surgery. Int J Oral Maxillofac Surg 1992: 21: 80. 8. TSUEDA K, CAREY W J, GONTY AA, BOSOMWORTH PB. Hazards to anesthetic equipment during maxillary oste0tomy: report of cases. J Oral Surg 1977: 35: 47.
Address: Dr L. B. Kaban Department of Oral and Maxillofacial Surgery University of California, San Francisco San Francisco, CA 94143-0440 USA