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LETTER TO EDITOR
Year : 2016  |  Volume : 10  |  Issue : 1  |  Page : 114-115

Complete airway obstruction with inferior turbinate avulsion after nasotracheal intubation


1 Department of Anesthesiology and Critical Care, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
2 Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India

Correspondence Address:
Sohan Lal Solanki
Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, 2nd Floor, Main Building, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.169492

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Date of Web Publication12-Nov-2015
 


How to cite this article:
Goyal VK, Solanki SL, Parekh AU, Gupta P. Complete airway obstruction with inferior turbinate avulsion after nasotracheal intubation. Saudi J Anaesth 2016;10:114-5

How to cite this URL:
Goyal VK, Solanki SL, Parekh AU, Gupta P. Complete airway obstruction with inferior turbinate avulsion after nasotracheal intubation. Saudi J Anaesth [serial online] 2016 [cited 2021 Apr 18];10:114-5. Available from: https://www.saudija.org/text.asp?2016/10/1/114/169492

Sir,

A 41 years, 78 kg and 176 cm, American Society of Anesthesiologists physical grade II male patient was posted for hemimandibulectomy. On preoperative check-up, he was hypertensive since 5 years on medication. His physical examination and investigations were within normal limit. Airway examination did not reveal any anticipated difficulty in oral or nasal intubation. He was Mallampati class I with a full range of neck movements. In the operating room, standard monitoring was attached and baseline parameters noted. Nasal passage was lubricated with 2% lignocaine jelly to desensitize the nasal mucosa and for smooth insertion of an endotracheal tube (ETT). Anesthesia was induced with intravenous fentanyl 2 μg/kg and propofol 2 mg/kg and tracheal intubation was facilitated with intravenous vecuronium 0.1 mg/kg. After 3 min of bag and mask ventilation, 7.5 mm ID cuffed ETT was passed through the right nostril with difficulty. On direct laryngoscopy, there was slight bleeding in the oral cavity, which was suctioned and ETT was advanced into the trachea with the help of Magill's forceps and cuff inflated. Breathing circuits was connected and on manual ventilation resistance was felt, end tidal CO 2 (ETCO 2 ) tracing was absent, there was no bilateral chest expansion and on auscultation bilateral air entry was completely absent with no sound on abdominal area too. ETT position was rechecked by direct laryngoscopy and found to be in correct position. ETT was immediately withdrawn and replaced with another ETT of the same diameter. On manual ventilation, bilateral chest expansion was observed and normal ETCO 2 waveform was present. On examination of removed ETT, the lumen at the patient end was completely occluded including Murphy's eye by soft-tissue possibly avulsed inferior nasal turbinate [Figure 1]. Postoperatively on 5 th day nasal endoscopy was done, and inferior turbinate avulsion was confirmed.
Figure 1: Endotracheal tube plugged with avulsed inferior turbinate

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Nasotracheal intubation is many times associated with complications, mostly mild and self-limiting nasal bleeding, severe hemorrhage, [1] structural damages, retropharyngeal dissection, [2] obstruction with foreign body, [3] and accidental turbinectomy. [4],[5] Trauma to inferior turbinates is more common than middle turbinates as it is closer to the nasotracheal tube. Deviated nasal septum and nasal spurs are considered to be a risk factor for trauma during intubation. Anesthesiologists, with experience, develop the judgment to apply the accurate pressure required to pass the tube into the trachea.

Once ventilatory difficulty is encountered, forceful ventilation should not be attempted. In our case, forceful ventilation would have dislodged the avulsed turbinate in the trachea or bronchus. We immediately removed the tube once difficulty in ventilation was encountered even after rechecking the ETT position by direct laryngoscopy. The exact cause for avulsion is not known but excessive pressure application while introducing the nasotracheal tube can be the reason. If excessive pressure is required than usual, to pass the tube then the tube should be withdrawn and redirected or passed through other nostril. [6] Even a bougie can be passed through the nostril, which is usually easier to pass and then the tube can be railroaded over it, in such conditions. Other preventive measure to avoid such complications such as selecting proper nostril for intubation by otolaryngologist consultation and opinion, endoscopic assessment of nasal cavity before intubation, [7] use of vasoconstrictor drops, adequate lubrication of tube and nostril, proper size of tube (smallest compatible), use of nasopharyngeal airway to dilate the nasal passages should be followed. [8] There are reports of adenoid avulsion in patient with normal and patent nasal cavity on proper preoperative otolaryngologist consultation and endoscopic examination [8] and fiberoptic anterior rhinoscopy failed to identify those in whom nasal intubation proved difficult or impossible. [9]

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

 
  References Top

1.
Piepho T, Thierbach A, Werner C. Nasotracheal intubation: Look before you leap. Br J Anesth 2005;94:859-60.  Back to cited text no. 1
    
2.
Knuth TE, Richards JR. Mainstem bronchial obstruction secondary to nasotracheal intubation: A case report and review of the literature. Anesth Analg 1991;73:487-9.  Back to cited text no. 2
    
3.
Blanc VF, Tremblay NA. The complications of tracheal intubation: A new classification with a review of the literature. Anesth Analg 1974;53: 202-13.  Back to cited text no. 3
[PUBMED]    
4.
Patiar S, Ho EC, Herdman RC. Partial middle turbinectomy by nasotracheal intubation. Ear Nose Throat J 2006;85:380, 382-3.  Back to cited text no. 4
    
5.
Zwank M. Middle turbinectomy as a complication of nasopharyngeal airway placement. Am J Emerg Med 2009;27:513.e3-4.  Back to cited text no. 5
    
6.
Smith JE, Reid AP. Asymptomatic intranasal abnormalities influencing the choice of nostril for nasotracheal intubation. Br J Anesth 1999;83:882-6.  Back to cited text no. 6
    
7.
Chen HH, Chen LC, Hsieh YH, Chen MK, Chen CH, Cheng KI. Unintended avulsion of hypertrophic adenoids in posterior nasopharynx: A case report of a rare complication caused by nasotracheal intubation. Case Rep Anesthesiol 2014;2014:980930.  Back to cited text no. 7
    
8.
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.  Back to cited text no. 8
    
9.
O'Connell JE, Stevenson DS, Stokes MA. Pathological changes associated with short-term nasal intubation. Anesthesia 1996;51:347-50.  Back to cited text no. 9
    


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