Mediastinitis Following Nasal lntubation in the Emergency Department MATTHEW SEAMAN, MD,* PAUL BALLINGER, T.D. STURGILL, MD,* MARK MAERTINS, A patient who developed a retropharyngeal abscess and fatal mediastinitlo following emergent nasal intubation is described. Despite aggressive surgical therapy the patient died of mediastinltis. Although mediastinitis as a complication of oral lntubatlon has been described, mediastinltis followlngnasal intubation has not previouslybeen reported. (Am J Emerg Med 1991;9:37-39. Copyright 0 1991 by W.B. Saunders Company)
Nasal intubation is associated with a variety of complications including epistaxis,‘** misplacement,3*4 inability to place the tube,la prolonged attempts,3,4 pressure necrosis,5 retropharyngeal laceration,’ retropharyngeal abscess,’ cellulitis,* sinusitis,6 auditory tube obstruction,’ bacteremia,8 obstruction of the nasotracheal tube,’ intracranial placement, lo and mucosal, tonsillar, and turbinate avulsion.7S9*‘1 Mediastinitis following nasal intubation has been considered a theoretical complication. ‘**A patient is described who developed fatal mediastinitis following nasal intubation.
CASE REPORT A 26-year-old woman with diabetes became unresponsive several hours after injecting 35 units of Mixtard (Nordisk-USA, Rockville, MD) insulin (30% regular insulin and 70% isophane insulin) subcutaneously; this was the patient’s usual dose of insulin. The patient failed to eat after administrating insulin. Bystanders summoned paramedics when the patient was found unconscious. The patient had a grand mal seizure for approximately 15 minutes during transportation to the hospital. No intravenous access could be obtained. Glucagon, 1 mg, was administered intramuscularly, but the seizure continued. On arrival at the hospital the patient continued to seize. It was elected to nasally intubate the patient for maintenance of airway control and ventilation. Phenylephrine hydrochloride 1% solution was first instilled into the nares. On the third passage, the patient was successfully intubated with a 7.0 mm Portex (Owens-Minor, Hillsboro, OR) blue line tube. With each intubation attempt, the tube was withdrawn into the nasopharynx before advancing. A sensation of increased resistance was not appreciated by the managing physician who performed the nasal intubation. Mild epistaxis was noted after placement of the tube. The patient became alert and was extubated. Blood drawn before administration of dextrose showed a glucose of 7 mg/dL. Intravenous access was obtained 11 minutes
From the ‘Department of Emergency Medicine and the TDepartment of Internal Medicine, Valley Medical Center, Fresno, CA. Manuscript received October 31, 1989; revision accepted April 1, 1990. Address reprint requests to Dr Seaman: Department of Emergency Medicine, Valley Medical Center, 445 S Cedar Ave, Fresno, CA 93702. Key Words: Nasal intubation, mediastinitis, retropharyngeal abscess. Copyright 0 1991 by W.B. Saunders Company 0735-6757/9110901-0010$5.00/O
MD,t MD,*
after the time of intubation. The patient became alert after administration of 25 g of 50% dextrose. The patient was then extubated. There was a past medical history of diabetes mellitus, seizures, alcohol abuse, intravenous drug abuse, pancreatitis, and alcoholic liver disease. There was no history of recent aural, oral, or dental infections. The patient was admitted to the hospital for improvement of her diabetic treatment regimen and treatment of alcoholic pancreatitis. Two days after admission the patient developed a fever, progressive neck swelling, and dysphagia. Soft tissue neck radiographs showed retropharyngeal edema and air within the soft tissues (Figure 1). Surgical drainage of a retropharyngeal abscess was performed. Pharyngeal inflammation and edema was observed; a distinct pharyngeal laceration was not seen. The patient was treated with cefotaxime, clindamycin, and penicillin. Cultures of the abscess grew Sraphylococcus aureus and group A P-hemolytic Streptococcus; both organisms showed sensitivity to the antibiotics. Anaerobic cultures showed no growth. A computed tomogram of the neck and chest obtained 1 days after drainage of the retropharyngeal abscess showed air extending into the mediastinum suggesting a mediastinal abscess (Figure 2). The mediastinal abscess was drained by a supraclavicular approach. The patient’s postoperative course was complicated by septic shock and multiple organ system failure. The patient was resuscitated from cardiac arrest on several occasions. Sixteen days after admission, the patient sustained a cardiac arrest and was unable to be resuscitated. Clinically the patient died of multiple organ system failure and shock. Additional findings at autopsy were the presence of diffuse alveolar inflammation, patchy tracheal mucosal necrosis, and brainstem infarction. There was no residual retropharyngeal or mediastinal abscess.
OISCUSSION The patient described in this paper developed a retropharyngeal abscess following nasal intubation that dissected into the mediastinum. Despite aggressive surgical intervention, the patient died of this infection. As a diabetic, intravenous drug abuser, and alcohol abuser, the patient was at risk for infectious complications of procedures such as passage of the nasotracheal tube. Nasal intubation is not a benign procedure. Up to 40% of patients who are nasally intubated will have some degree of epistaxis.3 Dislodgement of mucosal tissue has been documented in 33% of patients who are electively intubated.’ Hold-up (transient increased resistance to passage of the tube) has been noted in 35% of patients.’ Bacteremia has been found in 5.5% of patients after nasal intubation.8 After nasal intubation in the emergency department, 2 patients in a series of 71 sustained retropharyngeal lacerations.’ Intracranial placement of a nasotracheal tube has been reported in a single patient. lo Difficult nasotracheal intubation can be due to a congenital pharyngeal bursa.‘* A variety of additional complications of nasal intubation has been described (Table 1). 37
38
AMERICAN
JOURNAL
OF EMERGENCY
TABLE 1.
MEDICINE
n Volume 9, Number
1 n January
1991
Complications of Nasal lntubation
Auditory tube obstruction Bacteremia Cellulitis Dislodgement of tonsils Epistaxis Failure to place Intracranial placement Laryngeal and tracheal trauma Maxillary sinusitis Mediastinitis Misplacement Mucosal avulsion Nasal necrosis Prolonged attempts to place tube Retropharyngeal abscess Retropharyngeal laceration Tubal obstruction (polyp, nasal concha, Turbinate avulsion Data from references
1 through
blood
clot)
11.
CONCLUSION FIGURE 1. Lateral neck showing retropharyngeal air and swelling.
Acute mediastinitis caused by extension of infection from the cervical region is a rare but well recognized complication.‘3”4 Bacteria are introduced into the retropharyngeal region at the time of traumatic intubation. A retropharyngeal abscess may dissect inferiorly into the mediastinum through the retrovisceral space.‘5S’6 Mediastinal extension of a retropharyngeal abscess is frequently letha1.17-‘9 Mediastinitis after traumatic oral intubation has been reported 20-22but mediastinitis after nasal intubation has not been p&iously described. Patients in status epilepticus usually require airway intubation for ventilation and airway control. Complications of airway intubation are not always avoidable. This report indicates that emergent nasal intubation can be complicated by the development of a retropharyngeal abscess with progression to fatal mediastinitis.
Computed tomogram of the chest showing air and swelling within the mediastinum.
FIGURE 2.
The patient reported in this paper developed a retropharyngeal abscess and mediastinitis after nasal intubation. Epistaxis, mucosal avulsion, pharyngeal lacerations and other traumatic and infectious complications occur with frequency; these complications are sometimes unavoidable. Physicians should be prepared to identify and manage the major and minor complications of nasal intubation. The authors photographic
would like to thank prints.
Anne Miller
who prepared
the
REFERENCES 1. Tintinalli JE, Claffey J: Complications of nasotracheal intubation. Ann Emerg Med 1981;10:142-144 2. Danzl DF, Thomas DM: Nasotracheal intubations in the emergency department. Crit Care Med 1980;8:877-681 3. lserson KV: Blind nasotracheal intubation. Ann Emerg Med 1981 ;10:468-471 4. Delaney KA, Hessler R: Emergency flexible fiberoptic nasotracheal intubation: A report of 60 cases. Ann Emerg Med 1988;17:919-926 5. Zwillich C, Pierson DJ: Nasal necrosis: A complication of nasotracheal intubation. Chest 1973;64:376-377 6. Arens JF, LeJeunne FE, Webre DR: Maxillary sinusitis, a complication of nasotracheal intubation. Anesthesiology 19?4;40:415-416 7. Stoelting RK: Endotracheal intubation. In Miller RD (ed): Anesthesia, ed 2. New York, NY, Churchill Livingstone, 1986, p 523-552 8. Dinner M, Tjeuw M, Artusio JF: Bacteremia as a complication of nasotracheal intubation. Anesth Analg 1987;66:480462 9. Harvey DC, Amorosa P: Traumatic nasotracheal intubation (letter). Anesthesia 1986;41:442 10. Horellou MF, Mathe D, Feiss P: A hazard of nasotracheal intubation. Anaesthesia 1978;33:73-74 11. Scamman FL, Babin RW: An unusual complication of nasotracheal intubation. Anesthesiology 1983;59:352-353 12. Gallagher JV, Vance MV, Cash B: Difficult nasotracheal intubation: a previously unreported anatomical cause. Ann Emerg Med 1985;14:258-260 13. Estrera AS, Landay MJ, Grisham JM, et al: Descending necrotizing mediastinitis. Surg Gynecol Obstet 1982;157:545552 14. Moncada R, Warpeha R, Pickleman J, et al: Mediastinitis
SEAMAN ET AL n MEDIASTINITIS FOLLOWING NASAL INTUBATION
from odontogenic and deep cervical infection. Chest 1978; 73:497-500 15. Oliphant MD, Wiot JF, Whalen JP: The cervicothoracic continuum. Radiology 1976;120:257-262 16. Payne WS, Larson RH: Acute mediastinitis. Surg Clin North Am 1969;49:999-1009 17. Rotstein OD, Rhames FS, Molina E, et al: Mediastinitis after whiplash injury. Can J Surg 1986;29:54-56 18. Pearse HE: Mediastinitis following cervical suppuration. Ann Surg 1938;108:588-611
39
19. Janecka IP, Rankow RM: Fatal mediastinitis following retropharyngeal abscess. Arch Otolaryng 1971;93:630-833 20. Uram J, Hauser MS: Deep neck and mediastinal necrotizing infection secondary to a traumatic intubation: Report of a case. J Oral Maxillofac Sur 1988;46:788-791 21. Hawkins DB, Seltzer DC, Barnett TE, et al: Endotracheal tube perforation of the hypopharynx. West J Med 1974;120:282286 22. O’Neill JE, Giffin JP, Cottrell JE: Pharyngeal and esophageal perforation following endotracheal intubation. Anesthesiology 1984;60:487-488
Nasal intubation is associated with a variety of complications including epistaxis,‘** misplacement,3*4 inability to place the tube,la prolonged attempts,3,4 pressure necrosis,5 retropharyngeal laceration,’ retropharyngeal abscess,’ cellulitis,* sinusitis,6 auditory tube obstruction,’ bacteremia,8 obstruction of the nasotracheal tube,’ intracranial placement, lo and mucosal, tonsillar, and turbinate avulsion.7S9*‘1 Mediastinitis following nasal intubation has been considered a theoretical complication. ‘**A patient is described who developed fatal mediastinitis following nasal intubation.
CASE REPORT A 26-year-old woman with diabetes became unresponsive several hours after injecting 35 units of Mixtard (Nordisk-USA, Rockville, MD) insulin (30% regular insulin and 70% isophane insulin) subcutaneously; this was the patient’s usual dose of insulin. The patient failed to eat after administrating insulin. Bystanders summoned paramedics when the patient was found unconscious. The patient had a grand mal seizure for approximately 15 minutes during transportation to the hospital. No intravenous access could be obtained. Glucagon, 1 mg, was administered intramuscularly, but the seizure continued. On arrival at the hospital the patient continued to seize. It was elected to nasally intubate the patient for maintenance of airway control and ventilation. Phenylephrine hydrochloride 1% solution was first instilled into the nares. On the third passage, the patient was successfully intubated with a 7.0 mm Portex (Owens-Minor, Hillsboro, OR) blue line tube. With each intubation attempt, the tube was withdrawn into the nasopharynx before advancing. A sensation of increased resistance was not appreciated by the managing physician who performed the nasal intubation. Mild epistaxis was noted after placement of the tube. The patient became alert and was extubated. Blood drawn before administration of dextrose showed a glucose of 7 mg/dL. Intravenous access was obtained 11 minutes
From the ‘Department of Emergency Medicine and the TDepartment of Internal Medicine, Valley Medical Center, Fresno, CA. Manuscript received October 31, 1989; revision accepted April 1, 1990. Address reprint requests to Dr Seaman: Department of Emergency Medicine, Valley Medical Center, 445 S Cedar Ave, Fresno, CA 93702. Key Words: Nasal intubation, mediastinitis, retropharyngeal abscess. Copyright 0 1991 by W.B. Saunders Company 0735-6757/9110901-0010$5.00/O
MD,t MD,*
after the time of intubation. The patient became alert after administration of 25 g of 50% dextrose. The patient was then extubated. There was a past medical history of diabetes mellitus, seizures, alcohol abuse, intravenous drug abuse, pancreatitis, and alcoholic liver disease. There was no history of recent aural, oral, or dental infections. The patient was admitted to the hospital for improvement of her diabetic treatment regimen and treatment of alcoholic pancreatitis. Two days after admission the patient developed a fever, progressive neck swelling, and dysphagia. Soft tissue neck radiographs showed retropharyngeal edema and air within the soft tissues (Figure 1). Surgical drainage of a retropharyngeal abscess was performed. Pharyngeal inflammation and edema was observed; a distinct pharyngeal laceration was not seen. The patient was treated with cefotaxime, clindamycin, and penicillin. Cultures of the abscess grew Sraphylococcus aureus and group A P-hemolytic Streptococcus; both organisms showed sensitivity to the antibiotics. Anaerobic cultures showed no growth. A computed tomogram of the neck and chest obtained 1 days after drainage of the retropharyngeal abscess showed air extending into the mediastinum suggesting a mediastinal abscess (Figure 2). The mediastinal abscess was drained by a supraclavicular approach. The patient’s postoperative course was complicated by septic shock and multiple organ system failure. The patient was resuscitated from cardiac arrest on several occasions. Sixteen days after admission, the patient sustained a cardiac arrest and was unable to be resuscitated. Clinically the patient died of multiple organ system failure and shock. Additional findings at autopsy were the presence of diffuse alveolar inflammation, patchy tracheal mucosal necrosis, and brainstem infarction. There was no residual retropharyngeal or mediastinal abscess.
OISCUSSION The patient described in this paper developed a retropharyngeal abscess following nasal intubation that dissected into the mediastinum. Despite aggressive surgical intervention, the patient died of this infection. As a diabetic, intravenous drug abuser, and alcohol abuser, the patient was at risk for infectious complications of procedures such as passage of the nasotracheal tube. Nasal intubation is not a benign procedure. Up to 40% of patients who are nasally intubated will have some degree of epistaxis.3 Dislodgement of mucosal tissue has been documented in 33% of patients who are electively intubated.’ Hold-up (transient increased resistance to passage of the tube) has been noted in 35% of patients.’ Bacteremia has been found in 5.5% of patients after nasal intubation.8 After nasal intubation in the emergency department, 2 patients in a series of 71 sustained retropharyngeal lacerations.’ Intracranial placement of a nasotracheal tube has been reported in a single patient. lo Difficult nasotracheal intubation can be due to a congenital pharyngeal bursa.‘* A variety of additional complications of nasal intubation has been described (Table 1). 37
38
AMERICAN
JOURNAL
OF EMERGENCY
TABLE 1.
MEDICINE
n Volume 9, Number
1 n January
1991
Complications of Nasal lntubation
Auditory tube obstruction Bacteremia Cellulitis Dislodgement of tonsils Epistaxis Failure to place Intracranial placement Laryngeal and tracheal trauma Maxillary sinusitis Mediastinitis Misplacement Mucosal avulsion Nasal necrosis Prolonged attempts to place tube Retropharyngeal abscess Retropharyngeal laceration Tubal obstruction (polyp, nasal concha, Turbinate avulsion Data from references
1 through
blood
clot)
11.
CONCLUSION FIGURE 1. Lateral neck showing retropharyngeal air and swelling.
Acute mediastinitis caused by extension of infection from the cervical region is a rare but well recognized complication.‘3”4 Bacteria are introduced into the retropharyngeal region at the time of traumatic intubation. A retropharyngeal abscess may dissect inferiorly into the mediastinum through the retrovisceral space.‘5S’6 Mediastinal extension of a retropharyngeal abscess is frequently letha1.17-‘9 Mediastinitis after traumatic oral intubation has been reported 20-22but mediastinitis after nasal intubation has not been p&iously described. Patients in status epilepticus usually require airway intubation for ventilation and airway control. Complications of airway intubation are not always avoidable. This report indicates that emergent nasal intubation can be complicated by the development of a retropharyngeal abscess with progression to fatal mediastinitis.
Computed tomogram of the chest showing air and swelling within the mediastinum.
FIGURE 2.
The patient reported in this paper developed a retropharyngeal abscess and mediastinitis after nasal intubation. Epistaxis, mucosal avulsion, pharyngeal lacerations and other traumatic and infectious complications occur with frequency; these complications are sometimes unavoidable. Physicians should be prepared to identify and manage the major and minor complications of nasal intubation. The authors photographic
would like to thank prints.
Anne Miller
who prepared
the
REFERENCES 1. Tintinalli JE, Claffey J: Complications of nasotracheal intubation. Ann Emerg Med 1981;10:142-144 2. Danzl DF, Thomas DM: Nasotracheal intubations in the emergency department. Crit Care Med 1980;8:877-681 3. lserson KV: Blind nasotracheal intubation. Ann Emerg Med 1981 ;10:468-471 4. Delaney KA, Hessler R: Emergency flexible fiberoptic nasotracheal intubation: A report of 60 cases. Ann Emerg Med 1988;17:919-926 5. Zwillich C, Pierson DJ: Nasal necrosis: A complication of nasotracheal intubation. Chest 1973;64:376-377 6. Arens JF, LeJeunne FE, Webre DR: Maxillary sinusitis, a complication of nasotracheal intubation. Anesthesiology 19?4;40:415-416 7. Stoelting RK: Endotracheal intubation. In Miller RD (ed): Anesthesia, ed 2. New York, NY, Churchill Livingstone, 1986, p 523-552 8. Dinner M, Tjeuw M, Artusio JF: Bacteremia as a complication of nasotracheal intubation. Anesth Analg 1987;66:480462 9. Harvey DC, Amorosa P: Traumatic nasotracheal intubation (letter). Anesthesia 1986;41:442 10. Horellou MF, Mathe D, Feiss P: A hazard of nasotracheal intubation. Anaesthesia 1978;33:73-74 11. Scamman FL, Babin RW: An unusual complication of nasotracheal intubation. Anesthesiology 1983;59:352-353 12. Gallagher JV, Vance MV, Cash B: Difficult nasotracheal intubation: a previously unreported anatomical cause. Ann Emerg Med 1985;14:258-260 13. Estrera AS, Landay MJ, Grisham JM, et al: Descending necrotizing mediastinitis. Surg Gynecol Obstet 1982;157:545552 14. Moncada R, Warpeha R, Pickleman J, et al: Mediastinitis
SEAMAN ET AL n MEDIASTINITIS FOLLOWING NASAL INTUBATION
from odontogenic and deep cervical infection. Chest 1978; 73:497-500 15. Oliphant MD, Wiot JF, Whalen JP: The cervicothoracic continuum. Radiology 1976;120:257-262 16. Payne WS, Larson RH: Acute mediastinitis. Surg Clin North Am 1969;49:999-1009 17. Rotstein OD, Rhames FS, Molina E, et al: Mediastinitis after whiplash injury. Can J Surg 1986;29:54-56 18. Pearse HE: Mediastinitis following cervical suppuration. Ann Surg 1938;108:588-611
39
19. Janecka IP, Rankow RM: Fatal mediastinitis following retropharyngeal abscess. Arch Otolaryng 1971;93:630-833 20. Uram J, Hauser MS: Deep neck and mediastinal necrotizing infection secondary to a traumatic intubation: Report of a case. J Oral Maxillofac Sur 1988;46:788-791 21. Hawkins DB, Seltzer DC, Barnett TE, et al: Endotracheal tube perforation of the hypopharynx. West J Med 1974;120:282286 22. O’Neill JE, Giffin JP, Cottrell JE: Pharyngeal and esophageal perforation following endotracheal intubation. Anesthesiology 1984;60:487-488
