Article Type : Case Report
Authors : Deepali Gupta, Arulmurugan Balasubramanian, Dhruv Gupta, Radha Panchapakesan, Steffi Paulson John, Youmna Ayman Faheem, Samia Al Saddik, Parineeta Gupta and Ashish Aneja
Keywords : Anaesthesia; Enlarged adenoids; Tonsils; Pre-existing narrowed airway
General anaesthesia is needed in Dental
restoration surgery of Pediatric patients to provide comprehensive dental care
when conventional dental treatment is not possible. During dental surgery
Nasotracheal intubation provide excellent access to oral cavity which
facilitates the surgical field. Many complications may occur during
nasotracheal intubation including bleeding and injury to the nasopharyngeal
airway. The enlarged adenoids serves as a mechanical obstacle on the
nasopharynx during nasotracheal intubation. Dental caries is the most common
chronic disease of childhood; it can cause severe pain, infection and impaired
quality of life. There is a higher incidence of dental caries in patients with special
needs because of inadequate plaque removal. Down syndrome children have
enlarged adenoids, tonsils and tongue with dental crowding, missing and
malformed teeth. This case presents very rare incidence of injury of enlarged
adenoid tissue during blind nasal intubation leading to obstruction of the
endotracheal tube in a Down syndrome child.
Down syndrome is a chromosome disorder associated with
an extra chromosome (Trisomy 21) resulting in intellectual disability with
specific physical features. Down syndrome is frequently seen in conjunction
with other medical problems. There is a higher incidence of epilepsy, diabetes,
leukaemia, skin disorders, hypothyroidism and other conditions. Craniofacial
complex of Down syndrome is smaller in size than normal individuals. The nasal
bone is acutely angled and shorter, with an underdeveloped frontal maxillary
process, giving an appearance of a retruded midface. The growth of both jaws is
retarded including the ramus and the body. Along with there may be enlarged
adenoids, tonsils, and tongues causing obstruction of the pre-existing narrowed
airway. Some individuals with Down syndrome experience more frequent sinus and
upper respiratory infections which can worsen airway obstruction. Due to non-cooperation , many of these patients are
scheduled for dental surgery under general
anaesthesia with nasal intubation .In this case we had child with Down syndrome
scheduled for full mouth treatment under GA but due to his enlarged adenoids,
blind nasal intubation resulted in the trauma of adenoid tissue leading to
unexpected obstruction in the endotrachial tube.
In this study, a case of 5 year old child, 20kg,
height 120 cm was referred to Anaesthesia department for pre-operative
assessment before scheduling a dental restoration surgery. Child on general examination, was short stature and had difficulty in
speech with physiologically normal
vitals .There were clear facial looks of
Down syndrome with skin eczema
,high-arch palate and macroglossia. Child also had history of adenoids
infection. He had not received any dental treatment before. Labs reports were
normal. Since the child was uncooperative so, we discussed and decided that his
dental treatment would be done under general anaesthesia in a hospital setting.
After primary assessment and detailed history child was referred to a
cardiologist, and a general paediatrician, and dermatologist in order to clear
his medical status. Parents were explained about advantages and disadvantages
of the general anaesthesia and written consent was taken. They were also informed
about NPO guidelines. After clearance from cardiology and paediatrician and
dermatologist, child was scheduled for dental restoration surgery. Child was
premeditated with oral midazolam 10 mg half hour before surgery to reduce the
anxiety of child. Monitors like, pulse oximeter, ecg and bp, etco2, temp were
connected once child shifted in operation room. General anaesthesia was induced
by inhalation through 6 -8%sevoflurane
using a face mask along with 50:50 %oxygen and nitrous oxide .According to a
standard protocol, an iv line with 24 G cannula was secured medications were
given intravenously, Inj glycopyrolate 0.1 mg , Inj Propofol 40 mg ,
dexamethasone 2 mg and Inj Rocuronium10
mg iv was administered. Otrivin nasal
drops were put in both nostrils. Nasal intubation was tried blindly on right nostril
with 5 mm reinforced tube. There was difficulty in passing the tube so with
some extra adjustments tube was passed and fixed at 17cm and child was
ventilated. Ventilator showed high pressure and desaturation to 84 %. The air
entry was less bilaterally and child started desaturating. Etco2 waveform was
not coming proper. Bleeding was there in oral cavity on direct laryngoscopy. We
hand ventilated the child and noted resistance in tube .oral cavity and Endotrache
tube was suctioned but suction Cather did not pass well inside the tube.
Breathing circuit was again connected and on manual ventilation again
resistance was felt, there with
Minimal chest expansion on both sides with inadequate tidal volume alarm on monitor. We then decided to remove the endotracheal tube immediately. On examination of the removed Et tube we find soft tissue at the tip, blocking the tube. It was possibly adenoid tissue. Child was ventilated by mask and suction was done to clear the oral cavity. Otrivin drops.05 % helped in vasoconstriction of the vessels. Once bleeding was stopped by otolaryngologist and endoscopic assessment of nasal cavity was requested. It was not done due to non-availability of small paediatric size fibre optic endoscope in our centre. Now the plan was to try nasal intubation or proceed with oral intubation for surgery. One more attempt through other nostril was decided with a railroad technique. Left nostril was chosen, liberal lubrication was done, Thermo-softening of the endotracheal tubes was done and smaller size ET was selected. A 10 FG soft suction catheter was passed through the floor of the nasal cavity, direct laryngoscopy done and the once the tip of the catheter was visible in the oropharynx, the thumb control part of suction Cather was cut. We used rail road technique to pass the lubricated tracheal tube with gentle pressure on catheter. It passed very smoothly. When the endotracheal tube was visible in the oropharynx, the catheter was gently pulled off, and intubation can be done as usual with help of magills forceps. This method is used to reduce trauma and bleeding to the nasal passages and soft tip catheter acts as nontraumatic pathfinder .Tube was well placed with good bilateral air entry. The case was done in 2 hours. Intra-operatively, paracetamol 15 mg/kg was given, along with Ringer’s Lactate 1?2 DNS 150 mL IV. In addition, dexamethasone 2 mg IV was also given with Ondansetron 1.5 mg IV.
Tranexamic acid 200 mg was also infused via IV for
management of postoperative haemorrhage and other complications. Atropine
0.06mg/kg and Neostigmine 0.05mg/kg were administered together to reverse
muscle relaxation when the dental procedures was completed. Pethidine 10 mg IV
was given for effective post-operative analgesia. The child was then shifted to
the ward after monitoring for 6 hours in the post anaesthesia care unit. After
which he stayed in the ward for 24 hours for observation of any postoperative
bleeding, fever or related complications. Child was discharged next day [1-12]
(Figure 1).
The enlarged adenoid can sometimes act as a mechanical
obstruction in the nasopharynx to complicate the nasotracheal intubation. NTI
navigation from the nasal valve area through the nasal cavity to the
nasopharynx is always blind so trauma and bleeding is not uncommon. We can take
preventive measure to avoid such complications by selecting proper nostril
before intubation, otolaryngologist consultation for enlarged adenoids and
endoscopic assessment of nasal cavity before endoscopic assessment of nasal
cavity before intubation. Many complications happening while doing the procedure
can be operator induced or due to anatomical variations. It is important for the
anaesthesiologist to know the basics of nasotracheal intubation in order to
manage the complications arising from procedure. Preliminary fiberoptic nasal
endoscopy has been suggested to have a role in the anaesthetic assessment and
management before nasal intubation. Dental
Restoration under GA is definitely more cost effective than repeated
dental procedures under sedation.
This case report and accompanying images are published
with the written informed consent of the patient.