Accidental Perforation of Submental Flexometallic Tube.

Oral and maxillofacial surgeries associated with complications due to endotracheal tube (ETT) damage are being reported in literature increasingly. In this case, we report a rare case of accidental perforation of a flexometallic ETT intraoperatively during an orthognathic corrective surgery, in a 19-year-old female patient in whom submental intubation had been performed. The complication was managed conservatively as the tissue debris created during the osteotomy drilling occluded the damage and caused a good seal of the damage, with minimal leak, and no airway compromise. The purpose of this article is to highlight these hazards and discuss alternative airway management approaches so that anesthesiologists can recognize these complications and be prepared to deal with them in a proper manner.

INTRODUCTION

Orthognathic surgery involves surgical manipulation of the facial skeleton to restore the proper anatomic and functional relationship in patients with dentofacial skeletal anomalies. Submental intubation enables intermittent intraoperative occlusion of teeth to check alignment, airway control with enhanced surgical exposure and is an alternative to tracheostomy when nasal and orotracheal intubation is deemed unsuitable.

However, accidental damage to the submental endotracheal tube (ETT) can prove fatal if not recognized and managed in time. We encountered a rare case of accidental perforation of a flexometallic ETT during an orthognathic surgery in a patient intubated submentally.

CASE REPORT

A 19-year-old female patient was diagnosed with vertical maxillary prognathism and deviated nasal septum. She was posted for anterior maxillary osteotomy Le Fort I with septoplasty. Preanaesthetic assessment revealed she had no significant medical history. Airway assessment, clinical examination, and routine investigations were normal. Informed consent was obtained, and she was taken up for surgery under American Society of Anesthesiologists Grade I.

In the operating theater, the difficult airway cart was kept ready. Monitors were connected. The patient was induced with standard anesthesia technique. A conventional orotracheal intubation was carried out with a size 7.0 mm ID cuffed flexometallic ETT with a detachable universal connector. Bilateral air entry was confirmed and ETT secured.

Under strict aseptic precautions, local infiltration with 2% lignocaine with adrenaline was carried out followed by 2 cm skin incision in the right submental region, adjacent to the medial aspect of the lower border of the mandible [Figure 1]. Blunt dissection was carried out until the mucosal layer in the floor of the mouth was incised, creating a wide surgical tunnel.

Figure 1

Incision and dissection during submental intubation procedure

While ventilating with 100% oxygen, a closed curved artery forceps was inserted intraorally through the tunnel. The deflated pilot balloon was grasped and pulled inferiorly to pass through the incision in the submental skin. The same maneuver was carried out with the proximal end of the ETT tube after the circuit was disconnected and connector detached. After the proximal end of the ETT emerged extra-orally, the connector was reattached and circuit connected. The intraoral part of the ETT was now on the floor of the mouth between the tongue and the lingual surface of the mandible. The final position of ETT was rechecked and ETT cuff reinflated. Bilateral air entry was equal. Pharyngeal packing was done. ETT was secured with 2–0 silk stay sutures. The feasibility of suctioning through the ETT was also checked.

During the subapical osteotomy, sudden bubbling was noted around the ETT while the surgeon was drilling on the lingual surface of the mandible. As the intraoral portion of the ETT was close to the lingual surface of the mandible, it was realized that the surgeon had accidentally damaged the ETT. Immediately, ETT position was reconfirmed. Cuff pressure was normal. The reservoir bag filling was slightly decreased. Airway pressures were normal with no decrease in SpO2 or EtCO2.

Our first thought was to replace the tube. However, the cumbersome conversion of submental to orotracheal intubation, the difficulty of using a tube exchanger and the risk of bleeding by damaging the pharyngeal mucosa at this stage of surgery, prompted us to continue the procedure by conservative management. There was good occlusion of the leak by the tissue debris created while drilling. Careful monitoring of the patient was carried out throughout the procedure.

On completion of the procedure, the stay sutures were removed, and submental was converted into orotracheal intubation. The wound was closed, and extubation was done. Postextubation vitals were stable. The patient was discharged on the 3rd day after an uneventful postoperative period.

On inspecting the ETT, the damage was approximately 20 cm from the proximal end surrounded by the occluding tissue debris created by the drilling, which was washed away with running water. Once the tissue debris was removed, we were able to find three punctures on the ETT [Figure 2].

Figure 2

Perforated submental flexometallic endotracheal tube

DISCUSSION

Submental intubation was first described by Hernández Altemir[1] as an alternative procedure to avoid tracheostomy and allow manipulation during orthognathic surgeries. Various modifications have been given by several authors.

Management of airway compromise is a challenge for the anesthesiologist. Complications include accidental extubation, kinking of the ETT, damage to ETT, and rupture of cuff. These complications may result in an inability to ventilate adequately, progressive desaturation, and pose a risk of aspiration.

Airway compromise can be recognized by various signs. Collapse of reservoir bag or ventilator bellow indicates a major leak in the anesthetic breathing circuit. Other signs are sound of gas leak, decreased or absent EtCO2, decreased or zero peak airway pressure and decreased expiratory gas flow measured by spirometer in breathing circuit. Decreased air entry on auscultation and absence of chest inflation are important clinical signs. The diagnosis is confirmed by switching to manual ventilation to feel for compliance of lungs. Direct laryngoscopy may be done to confirm the position of ETT. Minor leaks may be compensated by increasing fresh gas flow.[2]

If the tear in the ETT is small, it is possible to approximate the damage by sealing the leak with wet gauze,[3] nylon ties,[3] adhesive tape,[3] cyanoacrylate glue,[4] or finger[5] to obtain a functional ETT. As a temporary measure, the tear in the tube can be bypassed by using smaller sized uncuffed ETT within the lumen of the damaged ETT as described by Peskin and Sachs.[6]

Chalkeidis et al.[7] reported a case of oral ETT damage during neurosurgical procedure in prone position, where the oral ETT was bitten and cut at two points. The anesthesiologist occluded the defect with a finger and surgery continued. Murthy et al.[8] reported an accidental transection of nasal ETT during surgery where they reintubated the patient orally. Drolet et al.[9] used a lubricated tube exchanger to replace a damaged ETT through the submental route with a fresh armored tube. The patient was ventilated through the port in the exchanger minimizing the chances of desaturation.

The last resort is to perform a tracheostomy as reported by Ladi and Aphale[10] where accidental transection of nasal flexometallic ETT during partial maxillectomy occurred. The difficulty in removing both proximal and distal ends of the transected ETT was overcome by doing tracheostomy. Once airway was established, cuff of the transected ETT was punctured, and remnants were removed.

In our case, there was an accidental ETT damage during drilling of the lingual surface of the mandible. The ideal solution was replacement of the tube. However, at that stage of surgery, significant bleeding was anticipated, and change of ETT looked cumbersome. We were able to maintain SpO2 and EtCO2 within normal limits and ventilate the patient adequately. Hence, we did not attempt to replace the ETT.

CONCLUSION

Airway compromise due to ETT damage is not uncommon in orthognathic surgeries. Only a prompt diagnosis and management can prevent fatal outcomes. It is important for anesthesiologists to be on alert to recognize and intervene in a timely manner.

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Conflicts of interest

There are no conflicts of interest.