Morbidity & Mortatlity

Nicole Weiss, MDAugust 24, 2011

64 y/o male with a h/o of a-fib, presenting for a hybrid mini-maze

Height:Weight:Airway Exam:

Malampatti: III Thyromental distance: II Mouth opening: II Thick Neck, Full Extension

***The Airway***On the up side, we could ventilateAttempt #1: Direct Laryngoscopy

Grade III/IV view; in light of DLT, handed over to staffAttempt #2: Direct Laryngoscopy

37 Fr DLT placed in esophagusAttempt #3: Glidescope

Grade I view Unable to pass DLT secondary to small mouth opening, difficult angle Attempted to use eschmann with glidescope, but too flimsy to make

curve Placed a single lumen ETT

Attempt #4: Cook Catheter Placed but unable to slide DLT over Single lumen ETT placed again

Attempt #5: Smaller Cook Catheter Still unable to pass DLT Single lumen ETT placed again

Case AbortedDecision made to cancel the case

Considered bronchial blocker, univent tube Safest option to simply stop

Plan: Extubate in a controlled setting & reschedule

the casePt taken to PACU intubatedPt admitted overnight for observation and discharged home the following morning

Unfortunately…this was not the end of the story

Patient continued to have persistent neck painReassuredTwo days later, still complaining of neck pain with an “expanding mass”, difficulty swallowingPresented to VA Urgent CareCT done…

Parapharyngeal, paratonsillar abscess (5.5x2.6cm)

Still not the end:Admitted to the ICUPlaced on IV antibioticsENT took back to the OR for a neck exploration

Found 2cm laceration of the right pillar tract that communicated and had fistulized to the right neck

Right submandibular, parapharyngeal abscessI&D grew out StrepIV antibiotics continued in houseFeeding tube placed for patient to be NPO for one week

Flint: Cummings Otolaryngology: Head and Neck Surgery, 5th edition

The morbidity of intubation

Intubation far most common cause of laryngeal trauma10% of patients have demonstrable laryngeal pathology one day after short term intubation for surgeryLonger term intubation results in laryngotracheal injuries in 90% of patients with long term sequelae in 11%

Was there a better option?

Glidescope or fiberoptic earlier?

Univent tube?Good for challenging airwaysDo not need to be exchanged after the case

Single lumen tube placed first with a cook catheter exchangeMay have been successful if done prior to anyway airway trauma