This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Eipe, N. Articles by Choudhrie, R. Search for Related Content PubMed PubMed Citation Articles by Eipe, N. Articles by Choudhrie, R.

---

LETTER TO THE EDITOR

Neck Contracture Release and Reinforced Tracheal Tube Obstruction

Department of Anesthesia; neipe{at}yahoo.com (Eipe) Department of Surgery (Choudhrie, Pillai) Department of Plastic Surgery; Padhar Hospital; Padhar, Betul, Madhya Pradesh, India (Choudhrie)

To the Editor:

Reinforced endotracheal tubes are useful for head and neck surgery during which kinking resulting from changes in the head position is likely. We report occlusion of a reinforced tube as a result of biting.

A 16-yr-old girl (35 kg) with a burn contracture of the neck was scheduled for surgery under general anesthesia (Fig. 1). She had a fixed flexion deformity of the neck with fixed mouth opening (interincisor distance 35 mm). Her jaw movements were limited, and she was unable to close her mouth. We planned an awake oral intubation after laryngoscopy and were also prepared for flexible fiberoptic intubation. After applying topical anesthesia to her oropharynx, preliminary laryngoscopy (1) revealed a Grade 3 view (2). Anesthesia was induced, and the trachea was intubated on the first attempt with a 7.0-mm inner diameter reinforced cuffed tracheal tube (Sheridan Spiral Flex Reinforced Tube; Hudson RCI, Temecula, CA). The surgeons released the neck contracture and covered the defect with a split-thickness skin graft. After release, the patient's mouth closed satisfactorily. The patient awoke comfortably, breathing satisfactorily. Just before the extubation the patient bit into the reinforced tracheal tube, completely and irreversibly occluding the lumen (Fig. 2). We immediately inserted an oropharyngeal airway and extubated the trachea. She maintained a good airway and had an unremarkable recovery.

View larger version (126K): [in this window] [in a new window]   Figure 1. Preoperative photograph showing the neck contracture and the inability to achieve incisor occlusion.

View larger version (109K): [in this window] [in a new window]   Figure 2. Bitten reinforced tracheal tube with luminal occlusion.

Reinforced tracheal tube occlusion (3) resulting from kinking or biting has been described, and the use of a soft bite block has been advocated to prevent this (4). Oropharyngeal airways offer additional protection but may not completely prevent the biting of the tube (5,6). Biting of the tube may result in perforation of the wall (7), unraveling of the wire (8) or complete transection of the tube (8). Once damage has been diagnosed the tube should be removed (9). Delayed detection of an occluded endotracheal tube may result in hypoxemia and or negative pressure pulmonary edema (10).

Although the reinforced tracheal tube will continue to be indispensable for neck contracture release and similar head and neck surgery, nasal intubation may be preferable to oral intubation to preclude this complication.

References

1. Eipe N. The chewing of betel quid and oral submucous fibrosis and anesthesia. Anesth Analg 2005;100:1210–3.[Abstract/Free Full Text]
2. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984;39:1105–11.[Web of Science][Medline]
3. Hoffmann CO, Swanson GA. Oral reinforced endotracheal tube crushed and perforated from biting. Anesth Analg 1989;69:552–3.[Free Full Text]
4. Negus B. Gauze bite block. Anaesth Intensive Care 1997;25:589.[Medline]
5. Kwan KM, Kok P, Koay CK. Prevention of tube occlusion caused by biting: oral bite block versus oropharyngeal airway. Anaesth Intensive Care 2000;28:227–30.[Medline]
6. King HK, Lewis K. Guedel oropharyngeal airway does not prevent patient biting on the endotracheal tube. Anaesth Intensive Care 1996;24:729–30.[Medline]
7. Harrison P, Bacon DR, Lema MJ. Perforation and partial obstruction of an armored endotracheal tube. J Neurosurg Anesthesiol 1995;7:121–3.[Medline]
8. Rodriguez R, Gonzalez H, Carranza A. Intraoral separation of a reinforced endotracheal tube. Anesthesiology 2000;93:908–9.[Medline]
9. Eisenach JH, Barnes RD. Potential disaster in airway management: a misguided airway exchange catheter via a hole bitten into a univent endotracheal tube. Anesthesiology 2002;96:1266–8.[Web of Science][Medline]
10. Eipe N, Choudhrie A. Nasal pack causing upper airway obstruction. Anesth Analg 2005;100:1861.[Free Full Text]

This article has been cited by other articles:

				R. L. Sheridan, D. P. Ryan, G. Fuzaylov, K. Nimkin, and J.A. J. Martyn Case 5-2008 -- An 18-Month-Old Girl with an Advanced Neck Contracture after a Burn N. Engl. J. Med., February 14, 2008; 358(7): 729 - 735. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Eipe, N. Articles by Choudhrie, R. Search for Related Content PubMed PubMed Citation Articles by Eipe, N. Articles by Choudhrie, R.