DAMAGE to the endotracheal tube is a well-known complication of maxillofacial surgery, 1–4especially when nasotracheal intubation has been performed. We present a case in which a damaged tube was repaired in situ , allowing a procedure to be completed safely.
A healthy 22-yr-old man was scheduled for a LeFort 1 osteotomy for correction of a maxillary and mandibular deformity. General anesthesia was induced using thiopental, morphine sulfate, and succinylcholine. Despite a laryngoscopic view of grade 3, as defined by Cormack and Lehane, 5a nasotracheal tube (Portex Polar Preformed Tracheal Tube; SimsPortex, Hythe, Kent, UK) was inserted on the first attempt. Anesthesia was maintained with use of nitrous oxide in oxygen, isoflurane, and pancuronium as needed. Controlled hypotensive technique (with sodium nitroprusside, labetalol, and droperidol) was used to maintain a mean blood pressure of approximately 50–60 mmHg.
Surgery began and continued without incident until the surgeon noticed bubbling around the tube. The surgeon had just performed a maxillary osteotomy with use of a pneumatic reciprocating saw and a protective metal shield, as recommended. 2A partially severed endotracheal tube was seen after adequate irrigation and suctioning in the back of the osteotomy site. The damage was approximately 21 cm from the proximal end of the tube. The length of the tear was 1.5 cm. No change in the shape of the end-tidal carbon dioxide curve or its value and no significant decrease in expiratory tidal volume or airway pressure were noticed. At this point, the estimated time until the end of surgery was 6 or 7 h. Because of an anticipated severe edema after the end of surgery, it was planned for the patient to remain intubated overnight. Our first thought was to replace the tube. However, the difficult laryngoscopy, the difficulty of using a tube exchanger or a fiberoptic bronchoscope, and the risk of damage to the pharyngeal mucosa with a new tube at this stage of surgery prompted us to search for an alternative to changing the tube. Sealing the hole in the tube with wet gauze was not thought to be adequate because the tube needed to stay in place until the next morning. The decision was made to try to fix the tear with use of cyanoacrylate glue (Dermabond; Ethicon, Somerville, NJ). Because of lack of experience or information regarding the effectiveness of the glue on this particular tube surface or possible interaction with its material, an in vitro experiment was performed first. A similar tear was made by the surgeon on a new maxillofacial tube. Glue was applied to this severed tube, and a complete seal was observed within seconds. Then, the patient’s tube was isolated from the surrounding tissues with gauze and was dried as much as possible. A small drop of cyanoacrylate was applied to the tear. The air bubbling stopped, and the surgery continued without incident. The patient was extubated in the postanesthesia care unit the next morning and discharged to his home a few days later. Evaluation of the repaired tube confirmed that the cyanoacrylate produced a complete and solid sealing of the damaged tube.
The ideal solution to a damaged tube is replacement of the tube. However, this is not always easy, especially at a stage of surgery at which bleeding may be significant. In the case presented, the laryngoscopic grade 3 view seen during induction caused us to seek an alternative. The shape of the preformed maxillofacial tube makes the use of a tube exchanger difficult. In the literature, there is a description of bypassing a tear with use of a smaller endotracheal tube inside the lumen of the severed regular tube, 4,6but there is no report of replacing or bypassing a damaged site of a special tube such as the one used in this case.
The cyanoacrylate glue used to seal the severed tube usually is indicated for use on live human tissue, such as in skin tears, to approximate wound edges or small surgical incisions. This topical skin adhesive is a sterile liquid that contains a monomeric (2-octyl cyanoacrylate) formulation. When applied, the liquid polymerizes within minutes. It is also used extensively in dental medicine as a tooth adhesive. The in vitro experiment we conducted prompted us to repeat it successfully in vivo . The glue should not be used on mucosal surfaces; therefore, we protected the nasal mucosa with gauze around the tube. The same experiment was performed on a clear polyvinyl chloride tube. However, in this case, 2 or 3 min were needed to achieve a complete seal of the tear.
Every anesthesiologist participating in the described type of surgery should be aware of the possible complication of damage to the tube during a LeFort osteotomy. When replacing the damaged tube is not the solution of choice, sealing the partially severed tube with cyanoacrylate glue might be an acceptable option.