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Perforation of and intubation through the palatoglossal fold.

A 58-year-old female collapsed at home. The ambulance service arrived ten minutes later and ventricular fibrillation was noted. After three cycles of defibrillation, sinus rhythm and circulation returned. A laryngeal mask airway was inserted for pre-hospital airway protection. At the local hospital the general medical practitioner intubated the patient after she vomited. To facilitate this, midazolam 2 mg and suxamethonium 75 mg were administered. The intubation was described as straightforward, with a grade 1 view of the larynx using a Macintosh blade. No stylet or bougie was used. The patient was referred to intensive care at Cairns Base Hospital.

On arrival, a right endobronchial intubation was noted. An electrocardiograph showed left bundle branch block and T-wave inversion in the inferolateral leads. Aspirin, clopidogrel and therapeutic clexane were prescribed. Active cooling was performed for 24 hours as part of our cerebral protection protocol. Several further episodes of ventricular fibrillation complicated the first 48 hours. On day three the patient had a fever, increased oxygen requirement, radiological evidence of right lower lobe consolidation and an intermittent inotrope requirement. Ceftriaxone and metronidazole were prescribed to treat a presumed lower respiratory tract infection.

Neurological recovery was slow and a percutaneous tracheostomy was inserted on day eight. During this procedure, it was noted that the endotracheal tube passed through the right palatoglossal fold before entering the trachea (Figure 1). Following tracheostomy tube insertion, the endotracheal tube was withdrawn leaving a palatoglossal fold defect (Figure 2). A tooth was also noted to be sitting freely in the posterior pharynx. On day 15 the patient was discharged from intensive care to the rehabilitation ward without noticeable complication.




This patient had an endobronchial intubation, dental trauma and perforation of the pharynx. It is uncertain when all these complications occurred. The dental trauma may have occurred prior to, during or subsequent to intubation with only 50% of dental injuries occurring during intubation (1). Similarly, the endobronchial positioning of the endotracheal tube may have occurred at intubation or during transfer. The pharyngeal perforation most certainly occurred at intubation. Despite this, the intubation was described as "easy" and the patient was ventilated satisfactorily for eight days. The endotracheal tube itself may have caused the perforation. However, aggressive suctioning (2,3) or incorrect positioning of the laryngoscope blade may have caused trauma.

Airway trauma during intubation is well recognised. Not surprisingly, there is a risk reduction with increased operator experience and when two operators are present. That is, a senior supervising a junior clinician as opposed to a single senior operator is protective (4). The risk is increased with the multiple variables contributing to difficult intubations and critically ill patients (3-6). For example, the rate of dental trauma may be increased from about 1:4500 in the elective setting (1) to 1:200 in critical care (5). Similarly, endobronchial intubation is a common complication1 with the risk in critically ill patients being 3 to 4% (5,6). There is also an association between difficult intubation and pharyngeal trauma (3). Pharyngeal perforation however, is very rare and thus the incidence is unknown. In this case the intubation was performed in a critically ill patient by an inexperienced operator in an environment not practised in the care of such patients.

Pharyngeal injury is associated with various adjuvants and alternatives to simple direct laryngoscopy and orotracheal intubation. While extremely rare, there are case reports of significant pharyngeal injury with the use of a stylet (7) or bougie (8). Alternatives to direct laryngoscopy do not eliminate the risk of airway trauma however. For example, fibreoptic intubations have been associated with trauma to the nasal passages, pharynx, larynx, trachea and oesophagus (1,9). Pharyngeal perforation has also been seen with the video laryngoscope (10-12). The lack of visualisation of the endotracheal tube during its passage through the oropharynx is thought to increase the risk of trauma (10-12). It is surprising then, that optical bougies/stylets may actually be protective with respect to dental and pharyngeal trauma (13-15). This may be due to the lack of suspension laryngoscopy. However, there are case reports of epiglottic trauma with the use of this technique (16). Apart from pharyngeal mucosal damage from high cuff pressures (17), the laryngeal mask as a conduit for endotracheal tube placement has a low incidence of airway trauma. There has however, been a case report of a fatal oesophageal rupture with blind intubation through an intubating laryngeal mask (18). The LMA CTrach[TM], with its fibreoptic visualisation, may not only increase the intubation success rate (19) but further decrease the risk of airway trauma.

Pharyngeal perforation is likely to be associated with a sore throat. In our patient however, sedation and subsequent slow neurological recovery may have concealed this symptom. Infection and bleeding could also be expected. It is difficult to be certain whether the fever and inotrope requirement on day three were not at least in part associated with a pharyngeal infection. Despite active cooling, anticoagulation and antiplatelet treatment however, no bleeding was observed. Subcutaneous, retropharyngeal and mediastinal emphysema are also possibilities (20), although our patient was protected from this by ventilation via the endotracheal tube. Although not yet reported with intubation trauma, it is theoretically possible to cause injury to the large vessels of the neck. That is, there are case reports of blunt and penetrating pharyngeal injuries in which either internal carotid artery or internal jugular vein thrombosis has occurred. This is presumably due to shearing forces on the vessel (21). Perhaps anticoagulant and antiplatelet therapy used in this case was protective.


This case report unfortunately illustrates again that direct laryngoscopy and intubation is not without risk. This is particularly so when the circumstances make it a difficult intubation. In addition, a review of the literature does not offer alternatives devoid of risk. It would appear that experience and supervision by an experienced operator may be the only reliable way to reduce risk.

Accepted for publication on December 22, 2008.


(1.) Hagberg C, Georgi R, Krier C. Complications of managing the airway. Best Pract Res Clin Anaesthesiol 2005; 19:641-659.

(2.) McHardy FE, Chung F. Postoperative sore throat: cause, prevention and treatment. Anaesthesia 1999; 54:444-453.

(3.) Domino K, Posner K, Caplan R, Cheney FW. Airway injury during anesthesia: a closed claim analysis. Anesthesiology 1999; 91:1703-1711.

(4.) Jaber S, Amraoui J, lefrant J, Arich C, Cohendy R, landreau L et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-centre study. Crit Care Med 2006; 34:2355-2361.

(5.) Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults: a prospective investigation of 297 tracheal intubations. Anesthesiology 1995; 82:367-376.

(6.) Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: a one year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325-332.

(7.) Tartell PB, Hoover LA, Friduss ME, Zuckerbraun L. Pharyngoesophageal intubation injuries. Am J Otolaryngol 1990; 11:256-260.

(8.) Kadry y, Popat M. Pharyngeal wall perforation--an unusual complication of blind intubation with a gum elastic bougie. Anaesthesia 1999; 54:404-405.

(9.) Kaneko Y, Nakazawa K, yokoyama K, Ishikawa S, Uchida T, Takahashi M et al. Subcutaneous emphysema and pneumomediastinum after translaryngeal intubation: tracheal perforation due to unsuccessful fiberoptic tracheal intubation. J Clin Anesth 2006; 18:135-137.

(10.) Vincent RD, Wimberly MP, Brockwell RC, Magnuson JS. Soft palate perforation during orotracheal intubation facilitated by the Glidescope videolaryngoscope. J Clin Anesth 2007; 19:619-621.

(11.) Hsu W, Hsu S, lee y, Huang J, Chen C. Penetrating injury of the soft palate during glidescope intubation. Anesth Analg 2007; 104:1609-1610.

(12.) Malik AM, Frogel JK. Anterior tonsillar pillar perforation during glidescope intubation. Anesth Analg 2007; 104:1610-1611.

(13.) Hung OR, Pytka S, Morris I, Murphy M, Lancelott G, Stevens S et al. Clinical trial of a new lightwand device (trachlight) to intubate the trachea. Anesthesiology 1995; 83:509-514.

(14.) Gravenstein D, Melker R, Lampotang S. Clinical assessment of a plastic optical fiber stylet for human tracheal intubation. Anesthesiology 1999; 91:648-653.

(15.) Davis L, Cook-Sather S, Schreiner M. lighted stylet tracheal intubation: a review. Anesth Analg 2000; 90:745-756.

(16.) Aoyama K, Takenaka I, Nagaoka E, Kadoya T, Sata T, Shigematsu A. Potential damage to the larynx associated with light-guided intubation: a case and series of fiberoptic examinations. Anesthesiology 2001; 94:165-167.

(17.) Keller C, Brimacombe J. Pharyngeal mucosal pressures, airway sealing pressures and fiberoptic position with the intubation verses the standard laryngeal mask airway. Anesthesiology 1999; 90:1001-1006.

(18.) Branthwaite MA. An unexpected complication of the intubating laryngeal mask. Anaesthesia 1999; 54:166-167.

(19.) Lui E, Goy Rw, Lim Y, Chen FG . Success of tracheal intubation with intubating laryngeal mask airways: a randomized trial of the LMA Fastrach[TM] and LMA Ctrach[TM]. Anesthesiology 2008; 108:621-626.

(20.) Wu K, Ahmed A. Penetrating injury to the soft palate causing retropharyngeal air collection. Emerg Med J 2005; 22:148-149.

(21.) Borges G, Bonilha L, Santos SF, Carelli EF, Fernandes YB, Ramina R et al. Thrombosis of the internal carotid artery secondary to soft palate injury in children and childhood. Pediatr Neurosurg 2000; 32:150-153.

D. S. BARTLETT *, R. GRACE ([dagger]), S. NEWELL ([dagger])

Department of Anaesthesia, Intensive Care and Perioperative Medicine, Cairns Base Hospital, Cairns, Australia

* B.M., B.S., Anaesthetic Registrar.

([dagger]) F.A.N.Z.C.A., Anaesthetic Consultant.

Address for reprints: Dr D. Bartlett, 128 McCormack St, Manunda, Cairns, Qld 4870.
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Author:Bartlett, D.S.; Grace, R.; Newell, S.
Publication:Anaesthesia and Intensive Care
Article Type:Report
Geographic Code:8AUST
Date:May 1, 2009
Previous Article:Anaesthesia and right ventricular failure.
Next Article:Intermittent positive airway pressure to manage hypoxia during one-lung anaesthesia.

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