We report a case of endotracheal tube damage that occurred during a maxillo-mandibular osteotomy and that was identified using a bronchofiberscope.
The patient was a 22-year-old man (height, 178 cm ; weight, 85 kg) who was scheduled to undergo a maxillo-mandibular osteotomy under general anesthesia for the treatment of two jaw deformities.
Anesthesia was induced with remifentanil and propofol. Rocuronium bromide was administered to facilitate muscle relaxation. Tracheal intubation using a Microcuff subglottic endotracheal tube (ID, 7.5 mm ; Halyard Healthcare Inc.) was performed via the left nasal cavity.
The anesthesia was maintained with air, oxygen, propofol, and remifentanil ; rocuronium was added as appropriate.
The surgery was initiated at the maxilla, and a maxillary transection was performed approximately 50 minutes later. The operator indicated that a ventilation gas leak had occurred after the maxillary transection, but examination using a bronchofiberscope did not reveal any abnormal findings. Because positive-pressure ventilation was possible and the ventilation was not problematic, we decided to resume the surgery. After the maxillary fixation was completed approximately 3.5 hours later and after a second bronchofiberscopic examination, we confirmed the inflow of blood into the tube and identified a tube laceration at around 4-5 cm from the nasal cavity entrance. We decided to conduct a tube exchange. We extubated the damaged tube and promptly performed oropharyngeal intubation. We carefully inserted a new tube into the nasal cavity and then extubated and promptly re-intubated the oral intubation tube.
After the surgery, the cause of the tube rupture was examined ; the tube was found to have been damaged by a bone chisel that had been used during the maxillary bone dissection. When endotracheal tube damage is suspected, confirmation of the inner surface using a bronchofiberscope is useful, and the early identification of such damage is important.
Anaphylaxis can occur during general anesthesia and is a serious complication for patients. We report a case of anaphylaxis in which a basophil activation test was used to identify the suspected agents. A 9-year-old boy was scheduled for dental treatment under general anesthesia at our hospital. Anaphylaxis immediately occurred following the induction of general anesthesia and the initiation of dental treatment. Therefore, we discontinued the procedure. Since the patient had a severe gagging reflex and multiple dental caries, general anesthesia was compulsory to proceed with treatment. Therefore, it was necessary to identify the suspected agent that had caused the anaphylaxis before performing a second general anesthesia induction. The patient and his parents did not provide consent for skin testing, which would have allowed us to identify the suspected allergen. However, they consented to undergo blood tests. We performed a basophil activation test (BAT), which was strongly positive for latex. Subsequently, we performed a second procedure with general anesthesia under latex-free conditions and completed the treatment successfully without a recurrence of anaphylaxis.
Skin tests are considered the most effective means of identifying agents suspected of causing anaphylaxis ; however, they are painful and involve a risk of inducing anaphylaxis during the test. Alternatively, the BAT has the advantage of not carrying such a risk. Moreover, BAT has increasingly attracted attention worldwide because of its high sensitivity and specificity for identifying suspected agents causing anaphylaxis and for having a diagnostic accuracy equivalent to that of skin testing. In the future, BAT is likely to be used more frequently in tests for anaphylaxis allergens under similar conditions.
Juvenile hyaline fibromatosis (JHF) is a rare autosomal recessive disease characterized by the presence of tissue nodules, joint contractures, and gingival hyperplasia. In the presently reported case, securing the airway and subsequent intubation were difficult because of the presence of oral and airway tumors and contracture of the jaw and cervical vertebrae. We performed anesthetic management for a 21-month-old patient with JHF who required a gingivectomy and the removal of a skin mass. We anticipated that securing the airway and achieving intubation would be difficult because of trismus, limited cervical movement caused by joint contracture, and narrowing of the oral space because of gingival hyperplasia. General anesthesia was induced using sevoflurane, nitrous oxide, and oxygen inhalation. We attempted to intubate the patient under video-laryngoscopic assistance (AIRWAY SCOPE® : AWS-S200NK, PENTAX) with a pediatric blade ; however, intubation was unsuccessful because the enlarged gingiva prevented the insertion of the blade. Therefore, we safely achieved nasotracheal intubation through both nostrils, providing ventilation through one side of the tracheal tube and inserting the video laryngoscope fiber through the other. The induction of general anesthesia in patients with JHF using oral devices and tools to secure the airway might be difficult because of gingival hyperplasia and joint contracture. Our experience from the present case suggests that nasotracheal intubation via both nasal cavities is effective for intubating patients with JHF.
Psoriatic arthritis (PsA) affects 15% of psoriasis patients, It also affects the temporomandibular joint (TMJ) at a much lower frequency. TMJ symptoms in PsA patients include positional abnormalities of the condyle, erosion, pain, or restricted movement in the incipient stage and fibrous or osseous ankylosis at an advanced stage. We report the general anesthetic management of a patient with psoriatic arthritis at the TMJ who required surgical treatment for TMJ ankylosis.
A 52-year-old man (weight, 80 kg ; height, 180 cm) was diagnosed as having psoriasis at the age of 23 years. He developed trismus at the age of 45 years and was diagnosed as having PsA 2 years later. He had subsequently undergone rehabilitation therapy for trismus, yet his maximum mouth opening was 7 mm. He had been treated with conservative therapy for an aortic dissection, which occurred at the age of 51 years. He was scheduled to undergo a gap arthroplasty for the release of the ankylosis of the TMJ under general anesthesia.
As a premedication, midazolam and atropine were administered intramuscularly. Nasotracheal fiberoptic intubation was performed under intravenous sedation with fentanyl and midazolam. General anesthesia was maintained with sevoflurane, fentanyl, and remifentanil. The perioperative systolic blood pressure was strictly controlled at less than 130 mmHg to avoid a relapse of the aortic dissection.
When anesthetizing patients with PsA, anesthesiologists should consider the individual-specific comorbidities, including cardiovascular diseases, and the possibility of a difficult airway because of TMJ ankylosis.
Marshall syndrome is characterized by mid-facial hypoplasia, high myopia, and upper airway malformations ; consequently, endotracheal intubation can be difficult. In the present case report, we utilized cephalography to evaluate the potential difficulty of endotracheal intubation prior to performing dental treatment in a patient with Marshall syndrome. Our previous study demonstrated that the retracted position of the mandible, a short mandible length, and a low hyoid bone position could be predictors of a difficult airway. We also analyzed the patency of the nasal tract on a CT image. In this manner, we were able to confirm that the mandible position was not abnormally retracted from the ANB angle measure of less than 3 SD or the facial angle measure of more than 3 SD ; thus, the mandible was not small enough to be categorized as a difficult airway based on a Gn-Cd measure of −1 SD. The position of the hyoid bone was also not too low, since the MP-H was −1 SD. General anesthesia was induced with nitrous oxide, sevoflurane, remifentanil, and rocuronium. We were able to intubate the patient smoothly through the predetermined nasal tract. The procedure was uneventful, and the patient was discharged from the hospital on the day of surgery. In conclusion, preoperative evaluations of difficult airways and intubation tract planning based on anatomical evaluations of cephalograms and CT images can be useful for securing safe airway management in patients with Marshall syndrome.
We supplied oxygen via reverse delivery after the normal means of oxygen supply was discontinued because of packing damage at a reel-type outlet ; we also clarified the cause of the damage and performed a repair. An alarm on the anesthesia machine sounded at the time of a start-up inspection, and a decrease in the oxygen supply pressure was detected. We immediately asked for an alternative oxygen supply and changed the machine. Immediately after the change, the central oxygen supply pressure decreased, indicating a possible leakage. An airtight test showed a leakage on the 3rd floor of the hospital but not on the other floors including the 5th floor, on which the operating room and ward are located. Since no leakage was detected on the 5th floor, we decided to utilize a reverse delivery oxygen supply. To shut off the operating room from the central supply system, the shut-off bulb was closed. An oxygen cylinder was then connected to the wall outlet. In addition to these actions, other sections were examined and the cause of the problem was clarified. We discovered that the packing at the connection site of a reel-type outlet in the Department of Pediatric Dentistry for the Disabled on the 3rd floor had been damaged. The packing was replaced on the same day. The presently reported planned operation was successfully performed. However, depending on the size of the institution and the number of operations, patient safety should be prioritized by cancelling elective surgeries or selecting other oxygen supply methods. Preventive measures to avoid oxygen supply interruption, management at the time of oxygen supply failure, and the sharing of equipment-related knowledge are important.
Metastatic lung cancer is common in cases with double cancers, including those with tongue cancer. A 73-year-old man (height, 158.8 cm ; weight, 51.9 kg) was scheduled to undergo the simultaneous resection of a tongue tumor and a left upper lobectomy.
Anesthesia was induced using remifentanil, propofol, and rocuronium. The tongue tumor was resected during nasal intubation. After the excision of the tongue tumor, a bronchial blocker was inserted via the nasal endotracheal tube. Then, a left upper lobectomy was performed. The arterial blood gases after insertion of the bronchial blocker were within the normal levels : FiO2, 0.6 ; pH 7.35 ; PCO2, 42 mmHg ; PO2, 315 mmHg ; and BE, −2.1 mmol/l. After surgery, the patient's oxygenation was good, and no respiratory complications occurred perioperatively.
Before the insertion of the bronchial blocker through the nasal endotracheal tube, the size, shape and location of the nasal space was confirmed using computerized tomography (CT). We predicted preoperatively that the lumen required for ventilation could be secured and calculated the required tube thickness using the outer and inner diameters of the intubation tube. In the present case, the required inner diameter was greater than 3 mm ; this diameter accounted for the deformation of the intubation tube into an oval shape as a result of compression from the nasal cavity tissue after its insertion into the nasal cavity.
Artificial intelligence analysis of PET-CT and CT images is becoming widespread, and the early detection of distant metastases of oral cancer is expected to increase. The simultaneous resection of oral cancer and pulmonary metastases is indicated for patients who are capable of undergoing a single operation.