The lost endotracheal tube--a rare complication of accidental esophageal intubation.

Endotracheal intubation is a discreet skill for the management of compromised airway. Various complications associated with this procedure have been described. Here, we would like to present a pediatric patient suffering from cerebellar atrophy, who was intubated in a local clinic due to seizure with cyanosis and loss of consciousness. Unfortunately, due to inadvertent esophageal intubation and bad management, the patient swallowed the endotracheal tube together with two detached loose teeth. This irrational and iatrogenic medical misconduct as exemplified in this accident calls forth the need of educating and disciplining the nonanesthetic physicians for acute management of airway, particularly of those who would likely come across difficult airway problems.