Sir,Accidental extubation is one of the important complications of airway management during general anaesthesia especially during head and neck surgery that requires urgent intervention to secure the airway. We witnessed a case of accidental extubation during parotidectomy and wish to report the same.A 40-year-old male patient (American Society of Anesthesiologists physical status 1), a known case of left parotid gland pleomorphic adenoma, was scheduled for parotidectomy. In the operation theatre, anaesthesia was induced by standard anaesthesia technique and the trachea was intubated with flexometalic 7.5-mm endotracheal tube (ETT) and fixed with the help of adhesive tape at right angle of mouth. The patient was placed in supine position with the head hyperextended and laterally rotated to expose the lesion side upward. The surgical site of interest was draped by the surgeon, and as a result we had very little access to the ETT.The surgery was started and continued smoothly for 1 h, but thereafter the ventilator showed significant leak of 100–200 mL. All the possible causes of leak were ruled out. The oxygen saturation started declining and reached 90%. Suddenly the ventilator showed disconnection and we found that the ETT was displaced and the trachea was extubated. The adhesive tape was found to be loose as it was soiled by excessive salivation and as a result the patient was extubated.In the Trendelenburg position, proper suctioning of the oral cavity was done. Immediate bag mask ventilation was started, and after that oxygen saturation improved to 100%. The trachea was reintubated and the ETT was secured with adhesive tape over which water-resistant transparent medical dressing was applied. The ETT was additionally fixed with the bandage around neck. Intravenous glycopyrrolate 0.2 mg was administered. During this event, the patient was haemodynamically stable. The course of surgery was uneventful thereafter, and the patient was extubated and transported to post-anaesthesia care unit.Inappropriate relaxation together with light plane of anaesthesia, loose cloth tape fixation, movement of patient's head during surgical exploration, accidental traction of ETT by the surgeon's hand and inappropriate tube fixation are some reasons behind accidental extubation.[1]The main intraoperative complication of the parotid surgery is facial nerve injury, but in this case we face an unusual and dreaded complication in the form of accidental extubation. To the best of our knowledge, it is the first case in which there is accidental extubation due to excessive salivation during parotidectomy.Saliva is secreted by the six major salivary glands (two parotids, two submandibular and two sublingual) and several hundred minor salivary glands. The minor salivary glands and the submandibular gland provide much of the saliva at rest, while the parotid gland is responsible for the majority of salivary production during stimulation.When stimulated, salivary flow increases by five times, with the parotid glands contributing the predominance of the saliva.[2] During parotidectomy, manipulation of the parotid gland can cause hypersalivation and if undetected early can lead to accidental extubation intraoperatively.The anaesthesiologist should be aware of this unusual intraoperative complication of parotid surgery. We suggest other method of tube fixation in parotid surgeries like fixing ETT with bandage in addition to adhesive tapes. Water-resistant medical dressing should also be applied over adhesive tape to prevent loosening of the same. In addition, intravenous glycopyrrolate should be administered after intubation to decrease the secretion.
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