Complete airway obstruction with inferior turbinate avulsion after nasotracheal intubation.

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 CO2 (ETCO2) 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 ETT was immediately withdrawn and replaced with another ETT of the same diameter.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 ETCO2 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 5th day nasal endoscopy was done, and inferior turbinate avulsion was confirmed.

Figure 1

Endotracheal tube plugged with avulsed inferior turbinate

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.[45] 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]

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