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Uvula necrosis after fibreoptic intubation

2018; Elsevier BV; Volume: 120; Issue: 5 Linguagem: Inglês

10.1016/j.bja.2018.02.011

1471-6771

Arne O. Budde, Christopher J. Parsons, Matthias Eikermann,

Trauma Management and Diagnosis

Uvula necrosis can occur as a rare complication of tracheal intubation. We highlight this troublesome complication by presenting a case of uvula necrosis after fibreoptic intubation. A 28-yr-old patient with abdominal pain and no other significant medical history presented for laparoscopic appendectomy. After an uneventful induction with propofol, fentanyl, and suxamethonium, we proceeded with an asleep fibreoptic intubation, which we consider an important alternative, standard technique to direct laryngoscopy that needs to be mastered by all anaesthesia providers. Initially, a 7.5 mm inner diameter tracheal tube was loaded onto a 4.4 mm outer diameter bronchoscope, which was easily inserted into the trachea. We then encountered significant resistance attempting to pass the tracheal tube over the bronchoscope despite rotating the tracheal tube around its axis and attempting multiple repositioning manoeuvres. After this unsuccessful attempt, the patient was mask ventilated and a 5.5 mm bronchoscope was loaded with a 7.0 mm tracheal tube to improve ease of passing the tube over the bronchoscope. After successful intubation, laparoscopic appendectomy was performed. About 90 min after the start of the procedure, the trachea was extubated without complication and the patient discharged home directly from the recovery room. He did not complain of sore throat or have signs of pharyngeal discomfort before discharge. On postoperative day 1, the patient called the surgeon's office to report pain and a sensation at the back of his throat that he described as a ‘tickle’. On a follow-up conversation on postoperative day 2, the tickling foreign body sensation had not improved, and the patient provided a selfie photo that reveals a demarcated necrotic portion of the distal uvula (Fig. 1A). The patient denied any dysphagia or difficulty eating or drinking and had no symptoms other than minimal pain and foreign body sensation. With pain treatment using over-the-counter analgesics, his sore throat and foreign body sensation resolved by postoperative day 4. A second selfie photo revealed a normal uvula with the necrotic portion seeming to have detached itself (Fig. 1B). There have been case reports describing postoperative uvula necrosis thought to be related to compression of the uvula by the tracheal tube.1Atkinson C.J. Rangasami J. Uvula necrosis—an unusual cause of severe postoperative sore throat.Br J Anaesth. 2006; 97: 426-427Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar While postoperative sore throat is a common anaesthetic complication, anaesthesiologists should consider uvula necrosis as a diagnosis in patients who report foreign body sensation in addition to severe sore throat after tracheal intubation.2Salengros J. Founas W. Digonnet A. et al.Uvular and tonsillar pillar mucosal necrosis as a cause of severe sore throat after orotracheal intubation.Anaesth Intensive Care. 2011; 39: 772-773PubMed Google Scholar In reviewing existing case reports, it seems that risk factors associated with uvula necrosis include: positioning the tracheal tube in the midline over the uvula, length of uvula with longer uvulae thought to have the potential to fold over on themselves causing poor blood flow; blind aggressive suctioning of the oropharynx, upper respiratory infection before surgery; recreational substance inhalation; and cigarette smoking.3Ziahosseini K. Ali S. Simo R. Malhotra R. Uvulitis following general anaesthesia.BMJ Case Rep. 2014; (pii bcr2014205038): 2014Google Scholar In our case, none of these risk factors was present; however, we believe that our multiple attempts to advance the tube over the bronchoscope may have caused trauma to the uvula by impingement of the tube.4Asai T. Shingu K. Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: incidence, causes and solutions.Br J Anaesth. 2004; 96: 870-881Abstract Full Text Full Text PDF Scopus (184) Google Scholar, 5Asai T. Murao K. Johmura S. Shingu K. Effect of cricoid pressure on the ease of fibrescope-aided tracheal intubation.Anaesthesia. 2002; 57: 909-913Crossref PubMed Scopus (29) Google Scholar An impingement of the tracheal tube under the epiglottis is a known mechanism of difficulty in advancing a tracheal tube over a fibrescope,5Asai T. Murao K. Johmura S. Shingu K. Effect of cricoid pressure on the ease of fibrescope-aided tracheal intubation.Anaesthesia. 2002; 57: 909-913Crossref PubMed Scopus (29) Google Scholar and we speculate that prolonged application of pressure to the tube with its tip being trapped in the supraglottic airway may also lead to a critical decrease of the blood flow to the uvula and surrounding structures, which should increase the vulnerability to necrosis. In conclusion, we observed uvula necrosis in a young man after a challenging fibreoptic intubation with prolonged impingement of the tube. Such a complication might be avoided by use of videolaryngoscopy, which is associated with reduced laryngeal and tracheal trauma.6Lewis S.R. Butler A.R. Parker J. Cook T.M. Schofield-Robinson O.J. Smith A.F. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review.Br J Anaesth. 2017; 119: 369-383Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar Uvula necrosis requires only conservative treatment but should nonetheless be considered a potential complication of fibreoptic intubation. M.E. is a member of the associate editorial board of the British Journal of Anaesthesia. The patient provided his written informed consent for reporting this case.