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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 2  |  Page : 205-207 Table of Contents     

Accidental Perforation of Endotracheal Tube during Orthognathic Surgery for Maxillary Prognathism - a Case Report


Assistant Prof., Department of Anesthesiology & Critical Care, Subharti Medical College, Meerut, U.P, India

Date of Acceptance04-Mar-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Manish Jain
A-5, Padam Kunj, Kishan Flour Mill, Railway Road, Meerut, U.P
India
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Source of Support: None, Conflict of Interest: None


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Maxillary prognathism(excess) is a congenital anomaly characterized by facial disfigurement. Accidental perforation of endotracheal tube during corrective surgery is not an uncommon complication. A case of accidental perforation of endotracheal tube during surgery and its management is presented here.

Keywords: Perforation; Maxillary prognathism; Orthognathic surgery


How to cite this article:
Jain M, Garg M, Gupta A. Accidental Perforation of Endotracheal Tube during Orthognathic Surgery for Maxillary Prognathism - a Case Report. Indian J Anaesth 2008;52:205-7

How to cite this URL:
Jain M, Garg M, Gupta A. Accidental Perforation of Endotracheal Tube during Orthognathic Surgery for Maxillary Prognathism - a Case Report. Indian J Anaesth [serial online] 2008 [cited 2019 Dec 15];52:205-7. Available from: http://www.ijaweb.org/text.asp?2008/52/2/205/60624


   Introduction Top


Maxillary prognathism imposes facial disfigurement that leads to dramatic psychic effects. Several ap­proaches were developed to correct this deformity.

Orthognathic surgery involves the surgical manipu­lation of the elements of the facial skeleton to restore the proper anatomic and functional relationship in pa­tients with dentofacial skeletal anomalies. Various sur­gical techniques for maxillary osteotomy are available. [1]

Restoring the orthognathic form of the face ulti­mately depends upon achieving the ideal facial aesthet­ics of the individual patient, not simply restoring the av­erage normative values of a population.

The number of individuals with developmental dentofacial deformities in the United States who may ben­efit from orthognathic surgery is estimated at 1.5-2 mil­lion; of these, approximately 1 million present with Class II deformities and 0.5 million with Class III deformities. [2]

Diagnosis is based on a comprehensive assessment that includes clinical examination, skeletal evaluation with standardized radiographs, and dental evaluation with study dental casts addressed as an integral part of the workup.

Dentofacial skeletal anomalies generally occur as a result of a differential in growth of the upper facial skeleton to the lower facial skeleton, resulting in dis­crepancy of the normal relationship that exists between the upper and lower jaw.Etiology includes genetic pre­disposition, trauma to face, neoplasms, surgical resec­tion, and iatrogenic radiation etc.

Indications for orthognathic surgery include facial dysmorphism with and without functional implications. Restoration of the normal anatomic relationship between the maxilla and mandible relative to the cranial base re­establishes the functional components (i.e., form and function) of the facial skeleton.


   Case report Top


A 23-yr-old female came to oro-maxillofacial sur­gery department for correction of facial deformity [Figure 1].She was diagnosed as a case of maxillary prognathism(excess)[Figure 2] and posted for orthogantic surgery (anterior/segmental maxillary osteotomy).On preanaesthetic check up, her weight was 45kg, medical history was insignificant, clinical examination and air­way was normal(MP grade I).Routine investigation re­vealed an Hb 11.6gm% with normal blood counts. She was accepted for surgery under ASA grade I. She was premedicated with oral. alprazolam 0.5 mg night before surgery. In the operation theatre, a peripheral vein was cannulated with 18 G cannula and Ringer lactate was started as i.v. fluid, glycopyrrolate 0.2 mg, midazolam 2.0mg, butorphanol 2.0mg was given i.v. as premedica­tion. Induction was done using propofol 100mg i.v. and nasotracheal intubation with RAE tube (Mallinckrodt RAE 7.0 NASAL) was facilitated by succinylcholine 100mg i.v.

Cuff was inflated and after confirming the position oropharyngeal packing was done. Anaesthesia was main­tained on nitrous oxide, oxygen, and halothane. Muscle re­laxation was provided by vecuronium bromide.Intra operatively patient's EKG, oxygen saturation, pulse rate, blood pressure and end tidal carbon dioxide were monitored. Sur­gery began and continued without incident until surgeon performed a maxillary osteotomy using a drill bit. Sudden bubbling was noted around the endotracheal tube. Immedi­ately position of ET tube was confirmed and it was found to be in place. ET tube cuff pressure was found to be nor­mal. There was collapse of reservoir bag along with de­crease in EtCO 2 level. Airway pressure was also decreased .We anticipated that tube had perforated during drilling of maxillary base. Oro-pharyngeal packing was removed and a tube changer(portex, no- 15 Ch 5mm x 60cm Sims Portex, Hythe, Kent, UK) after lubrication with water based jelly was inserted through ET tube and tube was removed. An­other ET tube of same size was threaded over the tube changer and position confirmed. Cuff of ET tube was in­flated and oropharyngeal packing was done. Rest of sur­gery was completed uneventfully.ET tube was inspected for defect. On inspection, damage was approximately 21 cm from the proximal end of the tube. The length of tear was approximately 1.0 cm.[Figure 3]

Discussion

Management of airway in patients having maxil­lary excess is a challenge for anaesthesiologist and is always associated with a potential threat of complica­tion causing airway compromise. This can prove fatal if not realized and attended in time. Potential complication include accidental extubation, damage to ET tube dur­ing surgery [3],[4],[5],[6] , and rupture of cuff. Perforation or transec­tion of ET tube is usually manifested by an apparent major leak in anaesthesia breathing circuit (detected by collapse of ventilator bellow or reservoir bag, smell of volatile anaesthetic, and sound of gas leak), hypoxemia, hypercarbia, decreased or absent endtidal carbon diox­ide, decreased or zero peak airway pressure and de­creased expiratory gas flow measured by spirometer in anaesthesia breathing circuit.

Management [7],[8],[9],[10] consists of­

  • Confirmation of diagnosis by switching to manual ventilation and feel for compliance of lungs.
  • Compensate leaks in anaesthesia breathing cir cuit by increasing fresh gas flow
  • Inform the surgeon
  • Direct laryngoscopy to confirm the position of ET tube and change it if required.
  • Standby for emergency tracheostomy if reintubation fails.
Potential complications of reintubation include­

  • Aspiration
  • Oesophageal intubation
  • Hypoxemia
  • Cardiac arrest
  • Contamination of surgical wound
Fortunately in our case, we did not encounter any of the above listed complications and patient was reintubated successfully with the help of tube changer in time. The postoperative period was uneventful and pa­tient had good recovery.

This complication is not uncommon during orthognathic surgery and only prompt diagnosis and management can prevent the fatal outcome.

 
   References Top

1.Johan P Reyneke,surgical technique,Essential of Orthognathic surgery,Quintessence publishing co.inc 2003,247-308,  Back to cited text no. 1      
2.Peter M.Sinclair,Paul M. Thomas and Myron R.Tucker,common complication in orthognathic surgery:etiology and management,William H. Bell,Modern Prac­tice in orthognathic and reconstructive surgery,W.B.Saunders co 1992,48-83.  Back to cited text no. 2      
3.Bidgoli SJ, Dumont L, Mattys M, Mardirosoff C, Damseaux P,et al. A serious anaesthetic complication of a Lefort I os­teotomy. Eur J Anaesthesiol 1999;16:201-3.  Back to cited text no. 3      
4.Pagar DM, Kupperman AW, Stern M, et al. Cutting of nasoendotracheal tube: an unusual complication of maxillary osteotomies. J Oral Surg 1978;36:314-5.  Back to cited text no. 4      
5.Thyne GM, Ferguson JW, Pilditch FD,et al. Endotracheal tube damage during orthognathic surgery. Int J Oral Maxillofac Surg 1992;21:80.  Back to cited text no. 5      
6.Mosby EL, Messer EJ, Nealis MF, Golden DP,et al. Intraop­erative damage to nasotracheal tubes during maxillary surgery: report of cases. J Oral Surg 1978 36:963-4.  Back to cited text no. 6      
7.Peskin RM, Sachs SA. Intraoperative management of a par­tially severed endotracheal tube during orthognathic surgery. Anesth Prog 1986;33:247-51.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Davies JR, Dyer PV. Preventing damage to the tracheal tube during maxillary osteotomy. Anaesthesia 2003;58:914-5.  Back to cited text no. 8  [PUBMED]    
9.Litchmore L, Sachs SA. Technique to minimize cutting the nasoendotracheal tube during maxillary osteotomy. J Oral Maxillofac Surg 1984;42:268-9.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Hought R, Zallen RD, Nathan R,et al. Use of a metallic nasal tube protector during maxillary osteotomy. J Oral Surg 1978;36:977.  Back to cited text no. 10      


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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