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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 100-102

Pilot tube misadventure during submental intubation - A new twist to the story!


1 Department of Anaesthesiology, Muthumeenakshi Hospitals, Pudukkottai, Tamil Nadu, India
2 Department of Oral and Maxillofacial Surgery, Muthumeenakshi Hospitals, Pudukkottai, Tamil Nadu, India
3 Department of Anaesthesiology, Kauvery Hospitals, Trichy, Tamil Nadu, India

Date of Web Publication28-Aug-2019

Correspondence Address:
Dr. Khaja Mohideen Sherfudeen
Muthumeenakshi Hospitals, Pudukkottai - 622 001, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ARWY.ARWY_18_19

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  Abstract 


The technique of submental intubation provides a secure airway and an unobstructed surgical field for adequate reduction and fixation of panfacial fractures. Procedural complications during submental intubation such as surgical difficulty, bleeding, flexometallic tube damage, migration of flexometallic tube, obstruction of flexometallic tube are well known. We faced a new problem during submental intubation because of the pilot tube which formed a loop inside the submental tunnel.

Keywords: Loop, pilot tubing, submental intubation


How to cite this article:
Sherfudeen KM, Ganesan R, Kaliannan SK, Ravichandran R P. Pilot tube misadventure during submental intubation - A new twist to the story!. Airway 2019;2:100-2

How to cite this URL:
Sherfudeen KM, Ganesan R, Kaliannan SK, Ravichandran R P. Pilot tube misadventure during submental intubation - A new twist to the story!. Airway [serial online] 2019 [cited 2019 Sep 20];2:100-2. Available from: http://www.arwy.org/text.asp?2019/2/2/100/265616




  Introduction Top


During intubation, problems related to pilot tubing system such as a severed pilot tube[1], cuff leak, kinking of pilot tube[2] and malfunction of pilot balloon system[3] have been reported. We report here a new problem with the pilot tube that we encountered during submental intubation.


  Case Report Top


A 20-year-old male with panfacial trauma was scheduled for open reduction and internal fixation under general anaesthesia with submental intubation. In the operation theatre, an 8.0 mm ID flexometallic tube was selected and the connector was checked for easy detachability. After establishing basic monitoring that included electrocardiogram, noninvasive blood pressure and pulse oximetry, the patient was premedicated with fentanyl 100 μg, midazolam 2 mg and glycopyrrolate 0.2 mg. Anaesthesia was induced with propofol 2 mg/kg. After confirmation of adequate bag-mask ventilation, vecuronium 6 mg was given and the patient intubated with an 8.0 mm ID flexometallic tube. The patient was positioned with head in extension and a 2-cm long paramedian incision was made in the submental region, about 1 cm from the lower margin of mandible and parallel to it, approximately one-third of the distance from the symphysis menti to the angle of mandible. Using a curved haemostat, blunt dissection was done along the lingual surface of mandible to create a passage. On pushing the tongue backward, the tip of the haemostat was visible below the mucosa in the floor of mouth. A mucosal incision was made over the tip of the haemostat and the haemostat pushed through into the oral cavity creating a passage for endotracheal tube. The connector of the flexometallic tube was detached. The pilot balloon was deflated, and the pilot tube grasped with the haemostat and gently withdrawn through the submental tunnel. The flexometallic tube was then grasped and withdrawn through the same tunnel. The connector was reattached to the endotracheal tube and ventilation restarted. The position of the flexometallic tube was rechecked with laryngoscopy, auscultation and capnography. A throat pack was placed and the endotracheal tube secured with 2-0 silk. Surgery was uneventful.

During extubation, it was noted that the pilot tube was short and pilot balloon was close to the skin at the level of fixation of the flexometallic tube. [Figure 1] Careful examination showed that the pilot tube of the flexometallic tube was entering and exiting through the same skin incision as the flexometallic tube. During extubation, the flexometallic tube was removed from its submental position following cuff deflation. Gentle traction was applied to the pilot tube but it was stuck. The pilot tube was cut near the pilot balloon, facilitating easy removal.
Figure 1: Flexometallic tube placed submentally with pilot tubing forming a loop near the skin

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Various problems related to the pilot tube system during oral intubation have been reported such as a severed pilot tube,[1] cuff leak, kinking of pilot tube[2] and malfunction of pilot balloon system because of bite block.[3] Procedural complications during submental intubation such as surgical difficulty, bleeding, damage to or migration of flexometallic tube, or obstruction of flexometallic are also well known.[4] However, the scenario we encountered is rare and has not been reported before.

At the submental skin incision, both the flexometallic tube as well as the pilot tubing system were exiting through the same incision. Intraorally also, only the flexometallic tube could be visualised and no part of the pilot tube was seen. It appeared that the pilot tube had formed a loop around the muscles beneath the mucosa. [Figure 2] We hypothesise that during the submental procedure, once the pilot tube was pulled out and the haemostat was reinserted into the tunnel to pull out the flexometallic tube, the haemostat could have split some muscles along the tract creating a different path and then exiting through the same mucosal incision. Thus, while there was a single opening both at the intraoral mucosal and skin levels, there were two separate tracts created within the submental tissues because of splitting of muscles around which the pilot tube had formed a loop. We overcame the clinical problem by cutting the pilot tube. Although not an unsurmountable misadventure, a complication of this nature should be borne in mind and undue force should not be used to pull out the pilot tube in such situations.
Figure 2: Diagrammatic representation of (a) normally positioned endotracheal tube placed submentally showing the normal path of the pilot tube system and (b) the pilot tube system creating a loop within the submandibular soft tissues

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his image and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bhandari S, Gupta SP, Gupta K, Kumar A. Accidental intraoperative avulsion of external inflation tubing of armored endotracheal tube. J Anaesthesiol Clin Pharmacol 2012;28:132-3.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Baduni N, Pandey M, Sanwal MK. Malfunctioning pilot balloon assembly. J Anaesthesiol Clin Pharmacol 2013;29:131-2.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Alkire MT. Ventilatory compromise secondary to occlusion of an endotracheal tube's balloon air channel by a malpositioned bite block. Anesthesiology 1998;88:1419.  Back to cited text no. 3
    
4.
Patkar GA, Virkar ND, Anusha MS, Tendolkar BA. A study of submental intubation for anaesthesia in patients with faciomaxillary injuries. Int J Clin Trials 2016;3:132-9.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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