Download Retropharyngeal dissection: A rare complication of nasotracheal

Retropharyngeal dissection:
A rare complication of nasotracheal
intubation revisited-A case report
WILLIAM W. LANDESS, CRNA, MS, JD
GrandLedge, Michigan
Nasotrachealintubation is commonly
performed by anesthesiapractitioners.
Knowledge of nasopharyngealanatomy is
essential to decrease the incidence of
complications. One such complication is
traumatic retropharyngealdissection.
Although it is rare, serious sequelae may
result. A case of a retropharyngealdissection
without untoward sequelae is described.
Recommendations and guidelines are
presented to assist the practitionerin the
event this complication is encountered.
Key words: Complications, nasotracheal
intubation, retropharyngeal dissection.
cal history included hypertension, legal blindness,
malnutrition, and depression. She was alert and
oriented and had ambulated well with a walker
before her injury.
Numerous falls were noted by history, with a
questionable past pelvic fracture. The patient stated
that she had frequent episodes of dizziness, which
probably caused the falls. However, she denied any
cardiac history. Medications included aspirin and
indapamide 2.5 mg daily.
The patient had a history of multiple anesthetics without any related difficulty. She had no
known allergies to medications and had been
Table I
Complications of nasotracheal intubation
Nasotracheal intubation is a common method of
airway control. Generally, this technique can be
accomplished without difficulty or untoward sequelae for the patient. The complications of intubation via the nasal route have been well documented
(Table I).1(p556),2(pp145, 158-159),3,4 This case report describes the management of a patient who exhibited
a traumatic retropharyngeal dissection associated
with nasotracheal intubation.
Case report
A 90-year-old white female, ASA physical status III, with a diagnosis of right femoral shaft fracture, presented to the operating suite for an elective
open reduction and internal fixation with intramedullary nailing. The patient's significant medi-
June 1994/ Vol. 62 /No. 3
1. Hemmorrhage (epistaxis)
2. Hematoma/abscess
3. Trauma to nasal septum
4. Turbinate fracture
5. Traumatic nasal polypectomy
6. Trauma to pharyngeal tonsils (adenoids)
7. Pharyngeal mucosal trauma or necrosis
8. Otitis and sinusitis
9. Bacteremia
10. Obstruction of eustachian tube
11. Airway obstruction
12. Retropharyngeal dissection
13. Forced air entry subcutaneous emphysema
14. Intracranial placement by basilar skull fracture
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cleared by the medical service for anesthesia and
surgery. The electrocardiogram, chest x-ray, and
laboratory analysis were essentially negative
(within normal limits for age), with the exception of
a hemoglobin of 9.2 g/dL, down from 11.4 g/dL on
admission.
The physical examination was relatively normal. The Mallampati airway class was not noted
during the preoperative examination; however, the
airway appeared normal. 5 After anatomical examination of the lumbar spine, the staff member completing the preoperative workup chose general anesthesia for this patient because of expected
difficulty with regional anesthesia. General anesthesia complications were considered, including
postoperative ventilation if endotracheal intubation was required. The patient and the patient's
family were advised of the risks, benefits, and options from the anesthetists's perspective, and informed consent was obtained.
The patient's preoperative medication consisted of indapamide 2.5 mg, ranitidine 150 mg, and
metoclopramide 10 mg by mouth 1 hour before the
8:00 AM surgery. An intravenous line of lactated
Ringer's was established with an 18-gauge catheter
in the right arm, which supplemented an existing
20-gauge intravenous line.
The patient was taken to the operating suite,
where standard monitors were placed, including
EGG, a noninvasive automatic blood pressure cuff,
and pulse oximetry. While breathing 100% oxygen
(02), the patient was induced with a combination of
low-dose midazolam, alfentanil, and propofol. Her
vital signs remained adequate, while the patient
was assist-ventilated with 100% 02 by face mask
with mild difficulty. Despite the difficulty, the oxygen saturation remained between 97 and 99%. Succinylcholine was used to facilitate intubation. Upon
documented relaxation by peripheral nerve stimulator, laryngoscopy ensued. The glottic opening
could not be visualized. Both Macintosh and Miller
blades were utilized to no avail. Despite the normal
outward appearance of the anatomy, the glottis was
superior (anterior) in position. It was curious that
the patient had reported multiple previous anesthetics without incident, considering this inability
to visualize the glottis.
The patient was ventilated by face mask with
100% 02 until spontaneous ventilation resumed.
No further anesthetics were given. Oxygen saturation remained at greater than 96%, at which time
blind nasal intubation was attempted with a 6.5-mm
internal diameter endotracheal tube. Standard
preparation for nasal intubation followed, including 4% lidocaine with phenylephrine and lidocaine
jelly nares preparation. Blind nasal intubation was
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attempted, but the endotracheal tube met with resistance bilaterally. For fear of trauma to the turbinates and mucosa, the attempt was discontinued.
The surgeon was then consulted concerning
the feasibility of canceling the procedure. The surgeon strongly felt that the patient's condition would
be compromised by delaying surgery. The patient's
falling hemoglobin and the possible complication
of pneumonia prompted the decision to continue.
It was felt that delaying the surgery would only
complicate the patient's hospital course.
The patient was awakened, and her vital signs
and pulse oximetry remained adequate. She was
turned onto her side for an attempt at spinal anesthesia with supplemental 02. Several unsuccessful
attempts at spinal anesthesia by both midline and
paramedian approaches followed. The orthopedic
surgeon offered to assist in spinal needle placement
using fluoroscopy. Despite the use of x-ray and the
involvement of two different experienced practitioners, the subarachnoid space could not be entered. Again the urgency of the surgery was questioned. After the previous concerns were reiterated,
use of general anesthesia was again entertained.
The patient was once again prepared for nasal
intubation.
With the patient supine and sedated, an attempt at a blind nasal intubation with a 6.0-mm
internal diameter endotracheal tube was made by
the second practitioner, who had extensive nasotracheal intubation experience. The tube passed the
turbinate area through the right naris without difficulty. However, the tube then met with resistance.
With the tube in that position, a laryngoscopy was
performed. It was then that the source of resistance
was recognized.
Behind the posterior pharyngeal wall was the
outline of the endotracheal tube, which appeared
to end in a pouchlike formation. The differential
diagnosis between retropharyngeal dissection and
anatomical anomaly was briefly considered. There
was no hemorrhage or evidence of hematoma. The
tube was withdrawn from the naris.
A successful oral intubation was subsequently
accomplished with the aid of a fiberoptic scope,
and the patient was then induced. Proper placement was confirmed by visual identification, equal
bilateral breath sounds, chest rise, tube condensation, and end-tidal carbon dioxide monitoring.
During the entire sequence of events, the patient had been continuously monitored and exhibited stable vital signs and satisfactory oxygen saturation with spontaneous respirations. Prophylactic
dexamethasone was given after successful intubation. Antibiotics were considered, but they were not
given at this time. The surgery then took place
Journalof the American Association of Nurse Anesthetists
without further complications. Before the conclusion of the procedure, laryngoscopic and fiberoptic
visualization revealed no hemorrhage or hematoma. Because of her age, physical status, and difficulty of intubation, the patient was transferred to
the intensive care unit with the endotracheal tube
in place for postoperative ventilation. She was subsequently weaned, extubated without difficulty, and
transferred to the floor.
Follow-up with this patient revealed no deleterious effects from her course of airway management.
Discussion
A 1984 article by Chait and Poulton, although
brief, was very informative.6 Retropharyngeal dissection occurs when the endoracheal tube dissects
the tissue plane of the posterior pharyngeal mucosa. The nasopharynx is the general entry site of
the mucosa. Overzealous efforts on the part of the
anesthesia provider can contribute to the event.
Bleeding may occur, and airway compromise is a
viable consideration. However, the bleeding is usually self-limiting. The patient may exhibit a sore
throat, which generally requires no intervention.
The incidence of retropharyngeal dissection
has not been quantified, because information is
scarce. Specific management information does not
appear to have been widely disseminated. Despite
this, there are several possible recommendations
the anesthesia provider can follow when faced with
this scenario. The initial concern is that of recognition. Once the problem has been recognized, overall management and treatment modalities must be
addressed.
The recommendations in Table II represent
the outcome of an extensive consultation with an
authoritative otolaryngologist, D. Mayhew, MD,
FACS, associate clinical professor of surgery, Michigan State University (personal communication,
November 1992).
Once the condition has been recognized and
the tube has been verified as being in the retropharyngeal space, it must be removed immediately.
Reintubation should then be accomplished by an
alternate route.
At that point or after the surgical procedure is
completed but before extubation, the oral cavity
and oropharynx should be inspected directly. It is
not only possible to inspect the oropharynx but also
the lower nasopharynx. During this inspection, the
nasopharynx may also be palpated. If a hematoma
of the nasopharynx is confirmed, incision and
drainage (not aspiration) should be accomplished
by an otolaryngologist at that time. The patient
should then be seen for follow-up evaluation within
12 hours.
June 1994/ Vol. 62/No. 3
Table II
Recommended guidelines for the management of
retropharyngeal dissection
1. High index of suspicion for complications
2. Recognition (visual or physiological parameters)
3. Immediate removal of nasotracheal tube
4. Reintubation by an alternate route
5. Inspect for hemorrhage prior to subsequent
extubation (visual, palpation, instrumentation)
6. Suspect possible hematoma formation
7. Consult otolaryngologist early ifretropharyngeal
dissection issuspected for appropriate
intervention
8. Consider use of dexamethasone
9. Initiate regimen of broad-spectrum antibiotics
10. Ensure otolaryngologist follow-up for ominous
manifestations:
A. Airway obstruction
B. Dyspnea
C. Dysphagia
D. Pain
E. Hyponasal phonation
F. Malaise
G. Fever
In the interim, the patient should be observed
for such signs of hematoma as a hyponasal voice or
the sensation of airway obstruction. Pain and fever
are possible indicators of a developing abscess, so
patient verbalization and temperature monitoring
are indicated. The patient should be placed on a
regimen of broad spectrum antibiotics prophylactically. In addition, in the days after the episode
whether a hematoma was present or not, the patient
should be urged to report any pain, malaise, dyspnea, voice change, or fever. There should be a
reexamination approximately 1 week after the
event. (The specific techniques of diagnosis and
intervention by the otolaryngologist have been excluded, since they are beyond the scope of this
article.)
The technique of nasotracheal intubation requires an intimate knowledge of the pharyngeal
anatomy. The pharynx is a musculomembranous
tube that extends from beneath the surface of the
skull to the level of the cricoid cartilage in front and
to that level of the intervertebral disc between the
fifth and sixth cervical vertebrae in back.
The pharynx is subdivided into three parts,
nasal, oral, and laryngeal. The nasopharynx lies
behind the nose and above the soft palate. It is
separated from the oropharynx by the soft palate.
The nasopharynx is a midline structure that communicates with the oropharynx by the choanae.
The orifice of the eustachian tube is located on its
lateral wall. The nasopharynx is composed of the
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mucous, fibrous, and muscular membranes. 7, 8 The
mucous portion is continuous throughout the nares.
Nasopharyngeal mucosa is vulnerable to damage. False passages (retropharyngeal dissection)
may be created.2 p153 , 6 Accessory sinuses drain into
the nasopharynx, making it possible for a major
entry portal for bacteria. The rich supply of blood
vessels create the ever-present danger of severe
epistaxis.
Serious consideration must be given before attempting intubation into an uncertain anatomy.3(P20 15) Preparation specific to the plan, as well
as alternate airway management, must be meticulous. Intubation through the nasal route can be
fraught with complications, such as epistaxis or
turbinate fracture. Technique and experience can
diminish both the number and severity of these
complications.
The nasopharynx may present with an abnormal anatomy, such as congenital malformations.
Adenoids, polyps, and turbinates may all be injured or displaced during the procedure. 3 Severe
epistaxis requiring intervention by an otolaryngologist may be necessary. Hemorrhage can complicate an already difficult situation. Nasal instrumentation requires gentle handling and patience
during manipulation to avoid difficulties.
Nasotracheal intubation can be accomplished
either by the blind technique or under direct visualization. The preoperative physical examination
will often elicit the most patent naris. By simply
occluding each naris in sequence, the more patent
naris can be identified. If necessary, visual examination can be accomplished. If there is no contraindication, the right naris should be chosen, because
it accepts the tube more readily due to the tube
configuration and the position of the Murphy eye.
The tube will more likely pass the Kesselbach's
plexus, as well as the turbinates, atraumatically.
Fractures of the turbinates are a dramatic complication. Application of a topical anesthetic 4% lidocaine) with a vasoconstrictor added (phenylephrine) provides a more patent access to the pharynx.
Alternatively, a 4% cocaine solution can be used.
After lubrication with a water-soluble lubricant (lidocaine jelly), a soft nasal airway can be passed to
determine patency. It should be noted that this soft
airway will only aid in determining the nares' patency; it does not guarantee further dilation of the
nares. 9 Trauma may still ensue during endotracheal tube placement.
If the blind technique is employed, the anesthesia provider, after completing the preparation
mentioned above, introduces the tube into the na-
than the calculated oral tube. This blind technique
is best used with the awake, sedated, or sleeping
patient who has spontaneous respirations. Using
gentle, steady pressure, the tube is advanced into
the posterior pharynx, just above the glottic opening. By listening to the respirations at their maximal point through the tube, the anesthetist can
verify the supraglottic position. The tube can then
be advanced through the cords on inspiration
(while they are open). It is not uncommon for the
tube to impinge on the anterior commissure of the
glottis. Flexion of the neck will be required to complete endotracheal intubation in this instance.
Extension will enable intubation when the tube
repeatedly enters the esophagus.' 1P 555) Usually, gentle rotation of the head (if not contraindicated), not
the tube, will facilitate successful intubation.
Generally, a cough is elicited and air is expelled through the tube. The tube should then be
advanced approximately another 2.5 to 4 cm to
move the cuff beyond the glottic rim. At this time
the cuff is inflated and its position is verified by
bilateral lung and epigastric auscultation, as well as
by end-tidal carbon dioxide monitoring. When the
patient is connected to the breathing circuit, the
reservoir bag movement will correspond to respirations. If he or she is not already anesthetized, the
patient is then induced.
In the unconscious patient who does not have
spontaneous respirations, the technique can be attempted blindly; however, its success is limited. It
is better to place the tube (as described above) at the
glottic opening, then use direct laryngoscopy and
MaGill forceps, if necessary, to pass the tube under
direct visualization.
It is imperative that esophageal intubation be
recognized and corrected immediately. All possible
modalities should be utilized, i.e., visual inspection, bilateral lung and epigastrium auscultation,
observation of chest rise, condensation in the tube,
reservoir bag movement, and end-tidal carbon dioxide confirmation. No single modality is conclusive. A combination of all modalities must be used
in order to verify proper endotracheal tube
placement. 2 3
There are various indications for nasotracheal
intubation, such as surgical field requirement, longterm placement, or a difficult oral approach. Nasotracheal intubation carries the possibility of serious
complications, such as infection, necrosis, and ulceration of the inferior turbinate, as well as sinusitis
and otitis.3
As with any technique, nasotracheal intubation has contraindications including coagulopathy,
ris at a nearly perpendicular (90-degree vertical)
angle. The tube is generally one full size smaller
pathology (such as congenital pharyngeal bursa),
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and certain facial fractures. 10 The classic contrain-
Journalof the American Association of Nurse Anesthetists
dication to nasal tracheal intubation is basilar skull
fracture. The tube may be introduced past the cribriform plate into the brain.
Summary
Retropharyngeal dissection is a rare complication of nasotracheal intubation. Although rare, this
complication, with possible dramatic effects, should
not be discounted. Serious sequelae may result from
retropharyngeal dissection, such as hemorrhage,
hematoma, or abscess formation, as well as subcutaneous emphysema if air is introduced by positive
pressure ventilation.
When faced with this complication there are
various actions that can be taken to improve patient
outcome. The recommendations made here are intended only as guidelines. Despite an exhaustive
literary search for this case study, there was a conspicuous absence of literature concerning this potentially devastating complication, prompting extensive reliance on textbooks and a specialty
consultation with an otolaryngologist for guidance.
Perhaps the lack of reported complications in
the current literature is due to the medicolegal
climate, but that would not explain the historical
absence of published reports. To alert and enlighten
anesthesia professionals, such occurrences should
be reported.
REFERENCES
(1) Barash PG, Cullen BF, Stoelting RK. ClinicalAnesthesia Philadelphia, Pennsylvania: J.B. Lippincott Company. 1981.
(2) Benumof JF. ClinicalProceduresin Anesthesia and Intensive Care. Philadelphia, Pennsylvania: J.B. Lippincott Company. 1992
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(3) Stone DJ, Gal TJ. Airway management. In: Miller RD ed.
Anesthesia 3rd ed. New York: Churchill Livingstone. 1990:1289.
(4) Tintinalli JE, Claffey J. Complications of nasotracheal intubation.
Ann Emerg Med 1981;10:142-144.
(5) Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict
difficult tracheal intubation: A prospective study. Canadian Anaesthetists
Society JournaL 1985;32:429-434.
(6) Chait DH, Poulton TJ. Case report: Retropharyngeal perforation,
A complication of nasotracheal intubation. Nebr Med J. 1984;March:
68-69.
(7) Gray H. Gray's Anatomy. Philadelphia, Pennsylvania: Running
Press. 1974:889-890.
(8) Wong YK, Novotny GM. Retropharyngeal space-A review of
anatomy, pathology, and clinical presentation. J OtolaryngoL 1978;7:
6,528-532.
(9) Adamson DN, Theisen FC, Barrett KC. Effect of mechanical dilation on nasotracheal intubation. J Oral Maxillofac Surg. 1988;46:372-375.
(10) Gallagher JV, Vance MV, Beechler C. Difficult nasotracheal intubation: A previously unreported anatomical cause. Ann Emerg Med.
1985;14:3,258-260.
AUTHOR
William W. Landess, CRNA, MS, JD, received his bachelor of
science in nurse anesthesia degree in 1985 and his master of science in
1993 from the University of Kansas Nurse Anesthesia Program. In 1992,
he obtained a juris doctorate from the Thomas M. Cooley School of Law
in Lansing, Michigan, and was admitted to the Michigan Bar the same
year.
Mr. Landess is an assistant professor of anesthesia for Michigan
State University. He is the chief anesthetist at St. Lawrence Hospital,
Lansing, Michigan, as well as the clinical coordinator for the Acute Pain
Management Service that is jointly operated by the university and the
hospital. He is also on the editorial board of the Anesthesia Malpractice
Protector.
ACKNOWLEDGMENTS
The author would like to thank Dr. Richard Ferro for supporting
this project, as well as Dr. Henry Beckmeyer for his continued commitment to the educational process. Also, his gratitude goes to Jan Claytor,
medical librarian. He extends special thanks to Twyla Landess, CRNA,
MS, for her support and to Chuck Biddle, CRNA, PhD, for being his
mentor and role model.
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