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From the *Division of Anesthesiology and Critical Care Medicine; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; and Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio.
Address correspondence and reprint requests to Maged Argalious, MD, Department of General Anesthesiology/E31, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195. Address e-mail to argalim{at}ccf.org.
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Abstract |
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METHODS: We describe a patient who underwent maxillomandibular advancement surgery, met criteria for tracheal extubation, and subsequently developed total airway obstruction immediately upon extubation.
RESULTS: Before extubation, an airway exchange catheter was used and reintubation occurred without difficulty. The patient was brought back to the operating room for evacuation of a hypopharyngeal hematoma, as well as revision and replacement of fractured hardware.
CONCLUSIONS: Nasopharyngolaryngoscopy should be performed routinely before extubating these patients to evaluate for pharyngeal edema and hematoma formation.
IMPLICATIONS: Maxillomandibular advancement (MMA) surgery is increasingly used as a surgical option in the treatment of obstructive sleep apnea. We report a case of life-threatening airway obstruction after MMA and discuss the etiology of airway compromise after these surgeries.
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Introduction |
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TopAbstractIntroductionCASE REPORTDISCUSSIONREFERENCES |
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The forward movement of the mandible/tongue complex enlarges the hypopharyngeal airway dimensions although improving the tension of the suprahyoid musculature.
The forward movement of the maxilla/soft palate complex results in enlargement of the pharyngeal airway dimensions although improving the tension of the velopharyngeal musculature, thus decreasing airway collapsibility. An earlier study (1) reported postoperative airway edema and hypopharyngeal hematoma in patients undergoing MMA. However, none of the study patients experienced postoperative airway compromise. The following case report is the first to describe total airway obstruction after MMA surgery.
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CASE REPORT |
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TopAbstractIntroductionCASE REPORTDISCUSSIONREFERENCES |
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In the operating room, the patient received topical and nebulized lidocaine 4%, and 2 mg of IV midazolam before awake fiberoptic nasal intubation with placement of a 7.5-mm reinforced endotracheal tube (ETT). Intraoperative anesthesia was maintained with oxygen, nitrous oxide, isoflorane, and rocuronium. Two large-bore peripheral IV catheters and a left radial arterial line were placed. Before incision, a first generation cephalosporin and dexamethasone (8 mg) were administered IV.
During the subsequent 9-h operation, a total of 500 cc of 6% hetastarch and 7200 cc of crystalloid were administered. Estimated blood loss was 700 cc, and intraoperative urine output was 910 cc. The decision to keep the patient tracheally intubated overnight was made on the basis of the long surgical duration, the extensive upper airway edema, surgical wiring of the jaw, and recommendation of the surgical team.
Upon arrival at the postanesthesia care unit, the patient was placed in a 30° head-up position and scheduled dosing of dexamethasone (8 mg IV every 6 h) was initiated. Sedation was maintained with propofol and fentanyl infusions. There was absence of ETT cuff leak, as described by Miller and Cole (2), upon arrival at the postanesthesia care unit.
The patient developed an ETT cuff leak approximately 14 h postoperatively. The propofol infusion was discontinued, and fentanyl infusion was decreased to 50 mcg/h. After spontaneous respirations were noted, the patient was weaned from synchronized intermittent mandatory ventilation to CPAP with 5 cm H2O of positive end-expiratory pressure/pressure support. Pulmonary mechanics and arterial blood gas analysis were within normal limits, adequate mentation was confirmed, sustained head lift was demonstrated, and there was no evidence of hemodynamic instability.
With the surgical team at the bedside, the patient was tracheally extubated using a 19F Cook Critical Care (Bloomington, IN) airway exchange catheter (AEC). Immediately after extubation, the patient attempted to initiate spontaneous breaths, but there was no significant air movement. Paradoxical chest and abdominal movements, and acute oxygen desaturation were noted as a result of the complete upper airway obstruction. The patient was immediately reintubated by advancing a lubricated 7.5 mm flexible tip ETT (Parker Flex-Tip Englewood, CO) over the AEC. CPAP ventilation and sedation were promptly reinitiated.
After the unsuccessful tracheal extubation, head and neck radiographs were obtained, revealing fracture of the surgical hardware. The patient returned to the operating room for a redo Le Forte I procedure with placement of titanium plates. During the surgical exploration, the hypopharyngeal hematoma was evacuated. Forty-eight hours postoperatively, he underwent a successful extubation using an AEC. The remainder of his hospital course was uneventful.
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DISCUSSION |
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TopAbstractIntroductionCASE REPORTDISCUSSIONREFERENCES |
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Cuff leak tests have been criticized because of their low sensitivity in detecting postextubation stridor (3). Their use is also limited in cases of pharyngeal pathology, as this case highlights because the nasal ETT acted as a splint, maintaining airway patency until the trachea was extubated.
The placement of an AEC does not guarantee airway patency after extubation, but is helpful in re-establishing a definitive airway by railroading an ETT over the AEC. In addition, the AEC can be used to ventilate the patient either via a bag-valve mask device or by jet ventilation through the "Rapi-fit" adapters supplied with the AEC until a more definitive airway can be established. The ability to jet ventilate the patient through the AEC can be confirmed before removal of the existing ETT (4–6).
Even though we were successful in advancing the ETT over the AEC, the possibility of failure to advance the ETT should be kept in mind. Potential causes of failure in advancing the ETT would include the ETT being caught against the arytenoids or due to the presence of a hypopharyngeal hematoma. The presence of surgeons at the bedside during extubation is therefore mandatory to remove the jaw wires expeditiously or to perform an emergency cricothyroidotomy. In addition, the necessary equipment for removal of the jaw wires, and for establishing a surgical airway, should also be at the bedside.
When choosing an AEC, the largest diameter catheter that will fit through the ETT should be chosen because larger size increases the success rate for reintubation, and also reduces the risk of barotrauma (7–9) during jet ventilation. AECs that lack a hollow lumen should be avoided as they do not allow for ventilation through them.
During MMA, the MM complex is typically advanced by 10 mm, which results in improved tension and reduced collapsibility of the suprahyoid and velopharyngeal musculature. The procedure involves osteotomies of the maxilla and mandible, along with the placement of plates and screws to fill the potential space created. These patients have a significant likelihood of postoperative airway edema and hematoma (Fig. 1). The extensive soft tissue dissection from surgical manipulation, as well as the osteotomy of the mandibular ramus, can result in edema, ecchymosis, and bleeding within the parapharyngeal space, and are the likely cause for the development of the hypopharyngeal hematoma in this patient. The fractured hardware probably contributed to the hematoma expansion by increasing the soft tissue dissection.
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Li et al. (1) used nasopharyngolaryngoscopy to evaluate postoperative airway changes after MMA surgery for OSA. Their data demonstrated that four of 70 patients (5.7%) developed clinically insignificant hypopharyngeal hematomas, 14 had edema/ecchymosis of the pyriform sinus/aryepiglottic fold, and all patients had mild to moderate lateral pharyngeal wall edema. Peak hematoma size occurred during postoperative Days 3 and 4. The authors therefore recommended routine nasopharyngolaryngoscopy in every patient within 48 h of MMA for OSA.
We conclude that patients undergoing MMA surgery for OSA are at high risk for postoperative airway complications as a result of their baseline airway characteristics, surgical airway manipulation, jaw wiring at the end of surgery, postoperative airway hematoma formation, as well as surgical complications related to hardware fracture. Nasopharyngolaryngoscopy should be routinely performed before tracheal extubation in patients with extensive maxillo-facial procedures to assess the degree of pharyngeal edema, and to evaluate for the presence of any hematoma. The use of AEC with ventilating capability and close communication with the surgical team is mandatory for a safe postoperative course.
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Footnotes |
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This article has been cited by other articles:
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  C. H. J. Won, K. K. Li, and C. Guilleminault Surgical Treatment of Obstructive Sleep Apnea: Upper Airway and Maxillomandibular Surgery Proceedings of the ATS, February 15, 2008; 5(2): 193 - 199. [Abstract] [Full Text] [PDF]
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 C. F. Viozzi Further Thoughts on Airway Management After Maxillomandibular Advancement for Obstructive Sleep Apnea Anesth. Analg., November 1, 2007; 105(5): 1517 - 1517. [Full Text] [PDF]
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