Letters to Editor
Posterior tracheal wall rupture following uneventful general endotracheal anaesthesia Sir, Posterior tracheal wall rupture is a rare, but serious iatrogenic complication of tracheal intubation.[1,2] The laceration usually occurs in the lower third of the trachea longitudinally at the posterior membranous wall or at the junction between the membranous wall and the cartilaginous ring. Over inflation of the cuff and sudden movement of the tube are the two most common reasons, and direct tear caused by the tube itself is rare.[3] Potential factors contributing to intubation‑related injury are vigorous coughing over tube, female sex, short stature, old age, inappropriate tube size, malposition of tube, oesophageal surgery and steroid therapy.[1‑3] In most cases, the initial presentation is cervicothoracic subcutaneous emphysema and dyspnoea.[1,4] Diagnosis is usually made by bronchoscopy or high‑resolution computed tomography. Although superficial tears may heal spontaneously, deeper and longer lacerations with increasing symptoms require prompt surgical repair.[1,3] We came across a case of tracheal rupture following uneventful endotracheal intubation. A 60‑year‑old lady with height of 145 cm and body weight of 62 kg (body mass index 29.49 kg/m2) was scheduled to undergo intercondylar fixation of right humerus. She had no comorbidity. After induction, endotracheal intubation was effected with 7.5 mm internal diameter (I.D.) cuffed tracheal tube through oral route. Standard anaesthesia techniques were followed with proper monitoring. The operative period was uneventful. Patient was extubated in the operating room after adequate reversal and shifted to the recovery ward. In the recovery room patient developed respiratory distress with surgical emphysema. Computed tomography scan showed a rent in the posterior tracheal wall. Bronchoscopy followed by surgical intervention was planned. Fibre optic bronchoscope (with preloaded endotracheal tube of 6.5 mm I.D.) was inserted through nasal route and a 4 cm longitudinal tear on the posterior tracheal wall ending 3 cm above carina was found. Patient was intubated over the Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014
bronchoscope and guided into the left main bronchus and one lung ventilation was initiated. The anterior wall of trachea was incised longitudinally, the tracheal tube was withdrawn after deflating the cuff and kept above this rent. Another tracheal tube of 5.5 mm I.D. was inserted through the incision and placed in the left main bronchus and one lung ventilation maintained. Posterior wall tear was repaired. Incision of the anterior wall was sutured starting from above. When it was near completion, second tracheal tube was taken out, and the first tracheal tube was advanced to position it just above the carina. Ventilation was adequate throughout the procedure. The patient was extubated on the next day. Post‑operative period was uneventful. A chest radiograph performed on day 7 showed complete resolution of the subcutaneous and mediastinal emphysema. The patient was discharged on day 8. A follow‑up bronchoscopy after 5 weeks revealed complete healing without stenosis. Post‑intubation tracheal rupture may present more frequently in women. Weaker pars membranosa and smaller tracheal diameters predispose women more vulnerable to cuff overinflation. Short stature and use of nitrous oxide could be other contributing factors[3] in our case. Consideration of post‑intubation tracheal rupture as a potential complication and increased awareness among the anaesthesiologists may lead to early diagnosis and prompt treatment. Intra‑operative manipulation of the airway and maintenance of adequate ventilation are also very critical.
Neetika Mishra, Tirtha Sahoo, Bikas Kusum Mandal, Sabyasachi Das Department of Anaesthesiology, North Bengal Medical College, Darjeeling, West Bengal, India Address for correspondence: Dr. Tirtha Sahoo, Department of Anaesthesiology, North Bengal Medical College, Sushrutanagar, Darjeeling ‑ 734 012, West Bengal, India. E‑mail: [email protected]
REFERENCES 1. Miñambres E, Burón J, Ballesteros MA, Llorca J, Muñoz P, González‑Castro A. Tracheal rupture after endotracheal intubation: A literature systematic review. Eur J Cardiothorac Surg 2009;35:1056‑62. 2. Joshi M, Mardakh S, Yarmush J, Kamath H, Schianodicola J, Mendoza E. Intraoperatively diagnosed tracheal tear after 357
Letters to Editor using an NIM EMG ETT with previously undiagnosed tracheomalacia. Case Rep Anesthesiol 2013;2013:568373. 3. Lim H, Kim JH, Kim D, Lee J, Son JS, Kim DC, et al. Tracheal rupture after endotracheal intubation: A report of three cases. Korean J Anesthesiol 2012;62:277‑80. 4. Kim KH, Kim MH, Choi JB, Kuh JH, Jo JK, Park HK. Postintubation tracheal ruptures: A case report. Korean J Thorac Cardiovasc Surg 2011;44:260‑5. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.135092
Right molar approach for uvulectomy of secondary non‑hodgkins lymphoma of uvula Sir, We appreciate the technique used and successful management of the case by Sharma et al.[1] and we applied the same for enlarged uvula. Enlarged uvula presents with difficulty in talking, fullness of oropharynx, difficulty in breathing and dysphonia. Neoplasm of uvula is very rare and we present here a case of non‑Hodgkins lymphoma secondary to chemo‑radiotherapy and anticipated difficult intubation. A 70 years old female with primary gastric non‑Hodgkins Lymphoma was being given chemotherapy at our regional cancer centre. After six cycles of chemotherapy (R‑CHOP: Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin and Prednisolone), she developed right extraorbital swelling for which she received radiotherapy. During end course of radiation, she developed enlargement of the uvula for which she visited ENT department. She presented with the complaint of difficulty in deglutition and breathing. On examination uvula was found red, swollen and enlarged. Uvulectomy was planned. Patient and family were explained about the procedure and consent for emergency tracheostomy obtained. Since surgery was elective one, orotracheal intubation was planned as nasotracheal intubation would have caused uvular injury. After instituting 358
routine monitoring, injection glyco‑pyrrolate 0.2 mg, injection palonosetron 0.075 mg and injection Fentanyl 50 µg were administered. Induction was effected with injection propofol 2 mg/kg and inj vecuronium bromide 0.1mg/kg was administered. With all precautions and difficult intubation cart ready, intubation was attempted with Portex®endotracheal tube 7.5 mm ID mounted over stylet through right molar approach avoiding injury to the uvula. A straight blade Miller’s laryngoscope was introduced from the right corner of mouth along the groove between the tongue and the tonsil, using leftward and anterior pressure to displace the tongue to the left. The blade was then advanced and its tip made to pass posterior to the epiglottis. Rotation of the neck and manipulation of the cricoid cartilage i.e optimal external laryngeal manipulation (OELM) improved glottic view. After successful endotracheal intubation was confirmed by bilateral chest auscultation and capnography, endotracheal tube was fixed in midline position slowly with the help of Boyle-Davis mouth gag through the opening for tracheal tube [Figure 1]. Surgery and course of anaesthesia were uneventful. Uvula was cut down and cauterisation done. The specimen was sent for histo‑pathological examination. The patient was reversed with injection neostigmine and injection glyco‑pyrrolate and sent to the ward from where she was discharged on 5th post operative day. The surgical histopathology report confirmed non‑Hodgkins Lymphoma. The right molar approach was used by Saxena et al. to tracheal intubation in child with Pierre‑Robin syndrome, cleft palate and tongue tie.[2] Patients presenting with intraoral swelling really pose a difficult laryngoscopy
Figure 1: showing enlarged uvula fixed in midline with Boyle-davis mouth gag Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Posterior tracheal wall rupture following uneventful general endotracheal anaesthesia Sir, Posterior tracheal wall rupture is a rare, but serious iatrogenic complication of tracheal intubation.[1,2] The laceration usually occurs in the lower third of the trachea longitudinally at the posterior membranous wall or at the junction between the membranous wall and the cartilaginous ring. Over inflation of the cuff and sudden movement of the tube are the two most common reasons, and direct tear caused by the tube itself is rare.[3] Potential factors contributing to intubation‑related injury are vigorous coughing over tube, female sex, short stature, old age, inappropriate tube size, malposition of tube, oesophageal surgery and steroid therapy.[1‑3] In most cases, the initial presentation is cervicothoracic subcutaneous emphysema and dyspnoea.[1,4] Diagnosis is usually made by bronchoscopy or high‑resolution computed tomography. Although superficial tears may heal spontaneously, deeper and longer lacerations with increasing symptoms require prompt surgical repair.[1,3] We came across a case of tracheal rupture following uneventful endotracheal intubation. A 60‑year‑old lady with height of 145 cm and body weight of 62 kg (body mass index 29.49 kg/m2) was scheduled to undergo intercondylar fixation of right humerus. She had no comorbidity. After induction, endotracheal intubation was effected with 7.5 mm internal diameter (I.D.) cuffed tracheal tube through oral route. Standard anaesthesia techniques were followed with proper monitoring. The operative period was uneventful. Patient was extubated in the operating room after adequate reversal and shifted to the recovery ward. In the recovery room patient developed respiratory distress with surgical emphysema. Computed tomography scan showed a rent in the posterior tracheal wall. Bronchoscopy followed by surgical intervention was planned. Fibre optic bronchoscope (with preloaded endotracheal tube of 6.5 mm I.D.) was inserted through nasal route and a 4 cm longitudinal tear on the posterior tracheal wall ending 3 cm above carina was found. Patient was intubated over the Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014
bronchoscope and guided into the left main bronchus and one lung ventilation was initiated. The anterior wall of trachea was incised longitudinally, the tracheal tube was withdrawn after deflating the cuff and kept above this rent. Another tracheal tube of 5.5 mm I.D. was inserted through the incision and placed in the left main bronchus and one lung ventilation maintained. Posterior wall tear was repaired. Incision of the anterior wall was sutured starting from above. When it was near completion, second tracheal tube was taken out, and the first tracheal tube was advanced to position it just above the carina. Ventilation was adequate throughout the procedure. The patient was extubated on the next day. Post‑operative period was uneventful. A chest radiograph performed on day 7 showed complete resolution of the subcutaneous and mediastinal emphysema. The patient was discharged on day 8. A follow‑up bronchoscopy after 5 weeks revealed complete healing without stenosis. Post‑intubation tracheal rupture may present more frequently in women. Weaker pars membranosa and smaller tracheal diameters predispose women more vulnerable to cuff overinflation. Short stature and use of nitrous oxide could be other contributing factors[3] in our case. Consideration of post‑intubation tracheal rupture as a potential complication and increased awareness among the anaesthesiologists may lead to early diagnosis and prompt treatment. Intra‑operative manipulation of the airway and maintenance of adequate ventilation are also very critical.
Neetika Mishra, Tirtha Sahoo, Bikas Kusum Mandal, Sabyasachi Das Department of Anaesthesiology, North Bengal Medical College, Darjeeling, West Bengal, India Address for correspondence: Dr. Tirtha Sahoo, Department of Anaesthesiology, North Bengal Medical College, Sushrutanagar, Darjeeling ‑ 734 012, West Bengal, India. E‑mail: [email protected]
REFERENCES 1. Miñambres E, Burón J, Ballesteros MA, Llorca J, Muñoz P, González‑Castro A. Tracheal rupture after endotracheal intubation: A literature systematic review. Eur J Cardiothorac Surg 2009;35:1056‑62. 2. Joshi M, Mardakh S, Yarmush J, Kamath H, Schianodicola J, Mendoza E. Intraoperatively diagnosed tracheal tear after 357
Letters to Editor using an NIM EMG ETT with previously undiagnosed tracheomalacia. Case Rep Anesthesiol 2013;2013:568373. 3. Lim H, Kim JH, Kim D, Lee J, Son JS, Kim DC, et al. Tracheal rupture after endotracheal intubation: A report of three cases. Korean J Anesthesiol 2012;62:277‑80. 4. Kim KH, Kim MH, Choi JB, Kuh JH, Jo JK, Park HK. Postintubation tracheal ruptures: A case report. Korean J Thorac Cardiovasc Surg 2011;44:260‑5. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.135092
Right molar approach for uvulectomy of secondary non‑hodgkins lymphoma of uvula Sir, We appreciate the technique used and successful management of the case by Sharma et al.[1] and we applied the same for enlarged uvula. Enlarged uvula presents with difficulty in talking, fullness of oropharynx, difficulty in breathing and dysphonia. Neoplasm of uvula is very rare and we present here a case of non‑Hodgkins lymphoma secondary to chemo‑radiotherapy and anticipated difficult intubation. A 70 years old female with primary gastric non‑Hodgkins Lymphoma was being given chemotherapy at our regional cancer centre. After six cycles of chemotherapy (R‑CHOP: Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin and Prednisolone), she developed right extraorbital swelling for which she received radiotherapy. During end course of radiation, she developed enlargement of the uvula for which she visited ENT department. She presented with the complaint of difficulty in deglutition and breathing. On examination uvula was found red, swollen and enlarged. Uvulectomy was planned. Patient and family were explained about the procedure and consent for emergency tracheostomy obtained. Since surgery was elective one, orotracheal intubation was planned as nasotracheal intubation would have caused uvular injury. After instituting 358
routine monitoring, injection glyco‑pyrrolate 0.2 mg, injection palonosetron 0.075 mg and injection Fentanyl 50 µg were administered. Induction was effected with injection propofol 2 mg/kg and inj vecuronium bromide 0.1mg/kg was administered. With all precautions and difficult intubation cart ready, intubation was attempted with Portex®endotracheal tube 7.5 mm ID mounted over stylet through right molar approach avoiding injury to the uvula. A straight blade Miller’s laryngoscope was introduced from the right corner of mouth along the groove between the tongue and the tonsil, using leftward and anterior pressure to displace the tongue to the left. The blade was then advanced and its tip made to pass posterior to the epiglottis. Rotation of the neck and manipulation of the cricoid cartilage i.e optimal external laryngeal manipulation (OELM) improved glottic view. After successful endotracheal intubation was confirmed by bilateral chest auscultation and capnography, endotracheal tube was fixed in midline position slowly with the help of Boyle-Davis mouth gag through the opening for tracheal tube [Figure 1]. Surgery and course of anaesthesia were uneventful. Uvula was cut down and cauterisation done. The specimen was sent for histo‑pathological examination. The patient was reversed with injection neostigmine and injection glyco‑pyrrolate and sent to the ward from where she was discharged on 5th post operative day. The surgical histopathology report confirmed non‑Hodgkins Lymphoma. The right molar approach was used by Saxena et al. to tracheal intubation in child with Pierre‑Robin syndrome, cleft palate and tongue tie.[2] Patients presenting with intraoral swelling really pose a difficult laryngoscopy
Figure 1: showing enlarged uvula fixed in midline with Boyle-davis mouth gag Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
