Journal of Dental Anesthesia and Pain Medicine

The Korean Dental Society of Anesthsiology (대한치과마취과학회)
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Endotracheal tube damage during surgically assisted rapid palatal expansion surgery; a case report

  • Badger, James (University Hospital Southampton NHS Foundation Trust, University of Southampton)
  • Received : 2020.01.07
  • Accepted : 2020.02.05
  • Published : 2020.02.28
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Abstract

Endotracheal tube damage is a well-known complication of maxillary surgery. We report a case of failure to ventilate due to superficial damage to the tubing between the cuff and pilot balloon in the nasal portion of a north facing Ring, Adair and Elwyn pre-formed endotracheal tube during Surgically Assisted Rapid Palatal Expansion surgery. The endotracheal tube was replaced uneventfully and surgery completed successfully. On reflection, we feel that that the vulnerable position of the cuff-pilot tubing significantly contributed to this critical incident and suggest that increased recognition of this is vital for the prevention of such cases in the future.

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References

  1. Peskin RM, Sachs SA. Intraoperative management of a partially severed endotracheal tube during orthognathic surgery. Anesth Prog 1986; 33: 247-51.
  2. George P, Fiadjoe JE, Simpao AF. An unusual lacerated tracheal tube during Le Fort surgery: literature review and case report. Case Rep Anesthesiol 2016; 2016: 6298687.
  3. Kim EJ, Yoon JY, Woo MN, Kim CH, Yoon JU, Jeon DN. Damage to the pilot balloon of the nasotracheal tube during orthognathic double-jaw surgery: A case report. J Dent Anesth Pain Med 2015; 15: 101-3. https://doi.org/10.17245/jdapm.2015.15.2.101
  4. Piroli A, Cutilli T, Lupi E, Marinangeli F, Varrassi G, Paladini A. Different solutions for damaged nasotracheal tube during maxillofacial surgery: a case series. Adv Ther 2019; 36: 1812-6. https://doi.org/10.1007/s12325-019-00968-9
  5. Himarani J, Nancy SM, Krishna Kumar Raja VB, Shanmuga Sundaram S. Management of an intraoperatively damaged endotracheal tube in a case of difficult airway using fibre-optic bronchoscope with minimal apnoea period. Indian J Anaesth 2017; 61: 347-9. https://doi.org/10.4103/ija.IJA_674_16
  6. Fagraeus L, Angelillo JC, Dolan EA. A serious anesthetic hazard during orthognathic surgery. Anesth Analg 1980; 59: 150-3.
  7. Adke M, Mendonca C. Concealed airway complication during LeFort I osteotomy. Anaesthesia 2003; 58: 294-5. https://doi.org/10.1046/j.1365-2044.2003.307024.x
  8. Bell RA. A review of maxillary expansion in relation to rate of expansion and patient's age. Am J Orthod 1982; 81: 32-7. https://doi.org/10.1016/0002-9416(82)90285-8