J Dent Anesth Pain Med.  2020 Feb;20(1):45-47. 10.17245/jdapm.2020.20.1.45.

Endotracheal tube damage during surgically assisted rapid palatal expansion surgery; a case report

Affiliations
  • 1University Hospital Southampton NHS Foundation Trust, University of Southampton, Southampton, United Kingdom. j.e.g.badger@soton.ac.uk

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.

Keyword

Airway; Complications; Damage; Endotracheal Tube; Surgically Assisted Rapid Palatal Expansion

MeSH Terms

Palatal Expansion Technique
Intubation, Intratracheal
Maxilla

Figure

  • Fig. 1 A photograph of the damaged endotracheal tube

  • Fig. 2 Location and extent of endotracheal tube damage. The grey outline represents a coronal section of the face. The circle is a transverse section of a pre-formed endotracheal tube in situ with the cuff to pilot balloon tubing within the lower border (black circle). The blue box represents studies where superficial damage to the endotracheal tube has been clinically significant due to cuff deflation. The red boxes represent the location of clinically significant damage as a result of > 50% transection.


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