A rare complication of mandibular surgery: Something to chew on!

Dear Editor,

The anesthetic management of a mandibular surgery is a challenge as the airway is shared by the surgeon and anesthesiologist. We report a case of immediate post-operative upper airway obstruction (UAO) due to a retained foreign body (Surgicel) that necessitated emergency cricothyrotomy after a mandibular surgery.

A 60 kg, 20-year-old man, in American Society of Anaesthesiologists functional class 1, was scheduled for mandibular plating and intermaxillary fixation (IMF) for fracture of the mandible. Preoperative examination of the airway revealed adequate mouth opening (interincisor distance IID > 2.5 FB) along with good range of cervical spine motion and it was classified as Mallampatti grade II. Induction of anesthesia and tracheal intubation were accomplished uneventfully with propofol 120 mg, fentanyl 100 mcg and vecuronium 6 mg intravenous (IV). Surgery lasted for 3 hrs and was uneventful. Neuromuscular blockade was adequately reversed at the end of surgery and inhalational anaesthetic discontinued. Small amount of blood stained mucus was suctioned from the patient’s nasopharynx. With the patient responding to verbal commands and having sustained head lift of >5 seconds, trachea was extubated. After few stridorous breaths and violent coughing, the patient pointed to his throat, indicating inability to breathe and a choking sensation. There was decreased air entry in the chest bilaterally with no added sounds. Airway obstruction was suspected and a nasopharyngeal suctioning was done to clear the airway, without much help. Positive pressure ventilation with 100% oxygen was administered without successful ventilation. Subsequently, propofol 30 mg was given IV to relieve the obstruction. Despite all these measures, the oxygen saturation (SpO2) progressively decreased to 50%, necessitating emergency cricothyrotomy. The SpO2 improved to 80% with this measure. We decided to proceed with tracheal intubation after giving 100 mg succinylcholine and removing thwe IMF. On laryngoscopy, a retained Surgicel was seen lying over the vocal cords. It was removed with the help of a Magill’s forceps and intubation performed with 7.5 mm endotracheal tube. Patient’s oxygen saturation improved thereafter and he was shifted to the ICU for observation.

Maxillofacial injuries may present with complex airway problems. According to Peterson et al., 67% of these complications arise during induction, 15% during surgery, 12% during extubation and 5% during recovery.[1] In the post-extubation period the patient may present with UAO due to laryngospasm, laryngeal edema, hemorrhage and vocal cord dysfunction.[2] Stridor has been reported post extubation in a patient who underwent sinus surgery due to aspiration of a nasal pack.[3] In our case, Surgicel (a hemostatic agent used to control bleeding, manufactured by Johnson and Johnson’s) had been accidentally left behind by the surgeon. As IMF had been done, we could not recheck for any foreign body. Respiratory arrest after few hours of IMF has also been reported wherein the patient had aspirated a wire fragment.[4]

Patients with IMF are at an increased risk for airway loss in the immediate postoperative period due to reduced mouth opening and accessibility.[4] Release of IMF might be necessary in case of emergency. We recommend that not only should wire cutters be kept ready in the extubation trolley, but also that the anesthesiologist be well versed with the procedure.