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LETTER TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 8  |  Page : 680-682  

Repeated cuff rupture with nasal intubation: What we learn!!!


Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Web Publication9-Aug-2019

Correspondence Address:
Dr. Narender Kaloria
Department of Anaesthesiology and Critical Care, 3rd Floor, OPD Block, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_275_19

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How to cite this article:
Kaloria N, Goyal S, Sethi P, Bhatia P. Repeated cuff rupture with nasal intubation: What we learn!!!. Indian J Anaesth 2019;63:680-2

How to cite this URL:
Kaloria N, Goyal S, Sethi P, Bhatia P. Repeated cuff rupture with nasal intubation: What we learn!!!. Indian J Anaesth [serial online] 2019 [cited 2019 Aug 19];63:680-2. Available from: http://www.ijaweb.org/text.asp?2019/63/8/680/264201



Sir,

A 55-year-old female, with pan facial trauma, was posted for facial reconstruction surgery for old healed bilateral fracture mandible and maxilla with saddle nose. On her preoperative visit, her mouth opening was less than one fingerbreadth. The preoperative x-ray of face and neck in both antero-posterior and lateral views showed patient air passage. All other preoperative investigations were within normal limits. As it was an anticipated difficult airway, awake fiberoptic nasal intubation was planned with appropriate preoperative counseling and written informed consent. The patient was nebulised with 4 ml of 4% lignocaine. The bilateral superior laryngeal nerve block was given, and nasal cavity was prepared with xylometazoline nasal spray to decrease vascularity. Awake nasal fiberoptic was done and the trachea was intubated with 7 mm internal diameter flexometallic endotracheal tube (fETT). The surgery was started but leak around the cuff observed with a decrease in tidal volume. The problem was not rectified with repeated cuff inflation, and it was assumed that the cuff was ruptured. So, a new fETT was inserted using a tube exchanger. Again, cuff leak was observed which could be due to cuff damaged during insertion. The nasal cavity was assessed with the little finger and a nasal spur was felt at the tip of the finger at the base of the nasal cavity. The nasal spur was not visualised under fiberoptic bronchoscope, probably because it was covered with mucosa layer. Oral intubation was not an option due to limited mouth opening, and dental alignment was also needed during the surgery. The further attempt of nasal intubation was also not possible due to the presence of the nasal spur. Submental intubation and tracheostomy were the only options left. We decided to proceed for submental intubation, which needed oral intubation. The surgeon released some adhesions from the temporomandibular joint. The mouth opening was two fingers breadth, after the release of adhesions. Direct laryngoscopy was performed, and the nasal fETT was removed over a bougie as a safety measure. Since the glottis opening was anterior, another bougie was passed orally to facilitate oral intubation under direct laryngoscopy [Figure 1]. Once the position of oral bougie was confirmed with a continuous trace of end-tidal carbon dioxide (EtCO2), the nasal bougie was removed and fETT was railroaded over the oral bougie. The proximal end of fETT was then pulled out through the surgically created hole to the submental space to make it submental intubation. The subsequent course of the surgery was uneventful. The consent for the possible publication was taken from the patient in the postoperative period.
Figure 1: Two bougies in situ, first was inserted through existing nasal ETT and another through the oral cavity under direct laryngoscopy

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The airway management is mostly difficult in facial reconstruction surgeries especially after pan facial trauma due to abnormal anatomy, reduced mouth opening, and fracture of facial bones.[1] These surgeries mainly involve mandible and maxilla, so either nasal or submental intubation is required, which also helps in maintaining proper dental alignment. Nasal intubation may require the help of fiberoptic bronchoscope. The submental intubation requires oral intubation first followed by taking out of proximal end of ETT with the pilot balloon through a surgically created opening in submental space near the inner aspect of mandible.[2],[3],[4] The bony spur is an abnormal growth of bone that commonly involves the bones of limbs and spine but may affect the bone of the nose. It may be diagnosed with a complete physical examination of the nose with a thorough history and few investigations such as x-ray, CT scan, or magnetic resonance imaging (MRI) of head and neck region.[5] In our case, the nasal spur was diagnosed with the palpation of the nasal cavity with the little finger which was subsequently confirmed by CT scan. [Figure 2]. The bony nasal spur was also reported intraoperatively which was diagnosed with repeated cuff rupture following nasal intubation.[6] It was an anticipated difficult airway with limited mouth opening, so the patient was intubated nasally, but the ETT cuff got ruptured from the nasal spur. Packing the peri-cuff area would have been an inefficient way to prevent leak as the expected time for surgical repair was 8 h. So, submental intubation was done after the release of adhesions around the mandible that resulted in mouth opening to two fingerbreadths. To conclude, the nasal spur can cause endotracheal tube cuff rupture following nasal intubation, which could be difficult to manage during facial reconstruction surgeries.
Figure 2: Axial section of computed tomography scan maxillo-facial region showing a nasal spur

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient's parent(s) has/have given his/her/their consent for his/her/their child's images and other clinical information to be reported in the journal. The parent(s) understand(s) that their child's names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Coupe MH, Johnson D, Seigne P, Hamlin B. Special article: Airway management in reconstructive surgery for noma (cancrum oris). Anesth Analg 2013;117:211-8.  Back to cited text no. 1
    
2.
Jabre P, Combes X, Leroux B, Aaron E, Auger H, Margenet A, et al. Use of gum elastic bougie for prehospital difficult intubation. Am J Emerg Med 2005;23:552-5.  Back to cited text no. 2
    
3.
Patteson SK, Epps JL, Hall J. Simultaneous oral and nasal tracheal intubation utilizing a fiberoptic scope in a patient with facial trauma. J Clin Anesth 1996;8:258-9.  Back to cited text no. 3
    
4.
Anwer HMF, Zeitoun IM, Shehata EAA. Submandibular approach for tracheal intubation in patients with panfacial fractures. Br J Anaesth 2007;98:835-40.  Back to cited text no. 4
    
5.
Smith JE, Reid AP. Asymptomatic intranasal abnormalities influencing the choice of nostril for nasotracheal intubation. Br J Anaesth 1999;83:882-6.  Back to cited text no. 5
    
6.
Thota RS, Doctor JR. Evaluation of paranasal sinuses on available computed tomography in head and neck cancer patients: An assessment tool for nasotracheal intubation. Indian J Anaesth 2016;60:960-1.  Back to cited text no. 6
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