|Year : 2008 | Volume
| Issue : 2 | Page : 205-207
Accidental Perforation of Endotracheal Tube during Orthognathic Surgery for Maxillary Prognathism - a Case Report
Manish Jain, Munish Garg, Amit Gupta
Assistant Prof., Department of Anesthesiology & Critical Care, Subharti Medical College, Meerut, U.P, India
|Date of Acceptance||04-Mar-2008|
|Date of Web Publication||19-Mar-2010|
A-5, Padam Kunj, Kishan Flour Mill, Railway Road, Meerut, U.P
Source of Support: None, Conflict of Interest: None
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|| |
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. 
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. 
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|| |
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]
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 ,,, , 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 ,,, consists of
Potential complications of reintubation include
- 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.
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.
- Oesophageal intubation
- Cardiac arrest
- Contamination of surgical wound
This complication is not uncommon during orthognathic surgery and only prompt diagnosis and management can prevent the fatal outcome.
| References|| |
|1.||Johan P Reyneke,surgical technique,Essential of Orthognathic surgery,Quintessence publishing co.inc 2003,247-308, |
|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. |
|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. |
|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. |
|5.||Thyne GM, Ferguson JW, Pilditch FD,et al. Endotracheal tube damage during orthognathic surgery. Int J Oral Maxillofac Surg 1992;21:80. |
|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. |
|7.||Peskin RM, Sachs SA. Intraoperative management of a partially severed endotracheal tube during orthognathic surgery. Anesth Prog 1986;33:247-51. [PUBMED] [FULLTEXT] |
|8.||Davies JR, Dyer PV. Preventing damage to the tracheal tube during maxillary osteotomy. Anaesthesia 2003;58:914-5. [PUBMED] |
|9.||Litchmore L, Sachs SA. Technique to minimize cutting the nasoendotracheal tube during maxillary osteotomy. J Oral Maxillofac Surg 1984;42:268-9. [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. |
[Figure 1], [Figure 2], [Figure 3]