M&M B.S.CRIBRIFORM PLATE PERFORATION:TECHNIQUES & MANAGEMENT OF NASOTRACHEAL INTUBATION Lyndsy Morton, BSN, SRNATMC School of Nurse Anesthesia

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Objectives

Review anatomy of nasopharyngeal airway Identify complications of nasotracheal tube

placement Describe the incidence of intracranial placement of a

nasotracheal tube and associated complications with nasotracheal intubation in adults

Identify best practices for placement of nasotracheal tube

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Case Study B.S.

B.S. 57 year old male, severe mental retardation On 11-14-2012, B.S. presented from Marshall

Rehabilitation Center with his caregiver. History of chronic generalized severe periodontitis

and caries ENT service consulted for removal of tooth # 6, 8, 11,

23, 24, 25, 26, and 32 prior to the continued orthodontic and prosthdontic treatment

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Case Study B.S.

Severe mental retardation directly related to blood-type mismatching as a newborn

Dental caries Severe periodontitis Diabetes mellitus GERD Allergic rhinitis

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Pre-op

No known procedure history

No known problems with anesthesia

No ETOH use, no tobacco, no drug use

LabsBlood glucose 91No additional labs

Height/weight/BMI167cm 77 kgBMI 27

NKDA

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Pre-op

Medication day of surgery: Zantac Flonase Glipizide

• Vital signs: HR 72 bpm BP 120/78 left arm O2 saturation 100% on RA RR 16 BRMIN

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Pre-op

Review of systems Airway

Normal neck range of motionMallampati Classification: IIIThyromental distance: >3FBMouth: Adequate opening, poor dentition

RespiratorySeasonal allergiesLow risk OSA (male, Age > 50)Lungs CTA, non-labored, BS equal

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Pre-op

Cardiovascular: Negative Functional capacity > 4 METS. Anesthesia physical exam: Regular rhythm, no murmur

Gastrointestinal: Constipation Reflux/heartburn/indigestion: controlled with

medication Renal/Endocrine:

Non insulin dependent diabetes mellitus (BS 91, 11/14/2012)

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Pre-op

Hematologic/Oncology: Denies cancer Blood-type mismatch as a newborn

Neurological Evaluation: Opens eyes spontaneously. Able to phonate some

words and sentences, mimics the examiner. Moves all extremities to command, deep tendon reflexes intact.

According to the examiners note, cranial nerves II through XII considered grossly intact.

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Anesthetic plan

Pretreatment with neosynephrine 1% nasal spray bilateral nares

Versed 0.5 mg Pre-oxygenate Standard propofol induction Test Ventilate

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Anesthetic plan

Mac 3 laryngoscope blade + McGill forceps 7.0 cuffed Nasal Rae ETT with 16 French red robinel

catheter lubricated with surgilube Desflurane Pain management with fentanyl

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Induction

12:38 1 % Neosynephrine spray applied to bilateral nares

12:39 Versed 0.5 mg IV 12:43 In room, EKG, pulse oximetry, blood pressure

cuff placed 12:49 Pre-oxygenated for 6 minutes 12:55 Induction (fentanyl 75 mcg, lidocaine 60 mg,

propofol 150 mg, succinylcholine100 mg) Able to bag ventilate

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Induction

Red robinel catheter inserted into the right naris and was unable to be visualized in oral pharynx. There was a moderate amount of bleeding at right naris despite atramatic advancement of tube

12:58 nasotracheal tube advanced a second time without red robinel catheter and was visualized via DL in oral pharynx

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Induction

McGill forceps were used to assist advancement of the tube through the vocal cords-Grade II view

13:00 secured at 28cm at right naris with positive bilateral breath sounds and positive end-tidal CO2

Oxygen saturation never dropped below 98% Blood pressure ranges during induction 100-198

systolic/103-56 diastolic

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Intra-op

Vital signs remained stable throughout the procedure

Dexamethasone 8 mg IV 1 Liter Lactated Ringers Emergence at 13:39

Opened eyes Adequate spontaneous respirations Oral pharynx suctioned Extubated Moved to cart

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Intra-op

EBL 50 ml Final vital signs 13:45

115/55, SpO2 100 on RA, HR 60, RR 20, Temp 97.0

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Post-op

Pt awake and alert No PONV Tolerating PO liquids VS 1435

128/64 HR 59 RR27 O2saturation 99 No apparent signs of anesthetic complications noted

Discharged to rehabilitation center at 1459

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11-15-2012 Post-Op Day 1

Admitted to Boone Hospital for neurological changes and positive findings on CT scan CT of head without contrast demonstrated

pneumocephalus with a collection of air in the frontal region and scattered air within the subarachnoid space surrounding the right hemisphere.

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11-15-2012 Post-Op Day 1

Towards the skull base near the midline there was a bubble of air at the level of the cribriform plate to the right of the midline. Fluid was noted along the right greater than the left ethmoid air cells. A paucity of bone bilaterally was noted at the cribriform plate with air at the skull base adjacent to the linear density through the parenchyma in a pattern suspicious for a passage tract.

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Diagnosis

Paucity of bone bilaterally at the cribriform plate Linear passage tract with adjacent

pnuemocephalus Edema noted along the passage tract However, no CSF leak was detected when

evaluation of upper nasal passage was performed No ischemic event was supported

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Treatment

B.S. was followed in the NSICU with serial examinations and serial studies

Neurosurgery concluded that there was no support for infectious challenges and no leakage

B.S. was placed on empiric antibiotics Arrangements were made to return to Marshall

Rehabilitation Center to continue his recovery

22 Plain CT of head showing malpositioned Foley catheter in left temporoparietal region (a and b).

(Sarkari, Tandon, Agrawal, Mahapatra, 2012)

23Path of insertion should be parallel to floor of nasal cavity along the inferior meatus or concha

Structures forming lateral wall of nasal cavity

(Hall & Shutt, 2002)

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Anatomical anomalies

(Hall & Shutt, 2002)

Non-symmetrical internal nasal structures Narrowing of nasal airways due to septal deviation

caused by trauma or normal anatomy Drying and ulceration of the mucosa Compensatory hypertrophy of the inferior

turbinate Septal spurs

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Nasotracheal intubation

A routine procedure in anesthesia and emergency medicine

Some indications include: Complex intra-oral and oropharyngeal surgery Mandibular reconstructive procedures When it may be impossible to get direct

laryngoscopic view of the larynx ex. trismus Intubation of patients with cervical spine injuries ICU patients that require prolonged weaning at

the end of surgery(Hall & Shutt, 2002)

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Risks of nasotracheal intubation

More common: Epistaxis 18-77% (sphenopalatine artery, a

continuation of the maxillary artery) Turbinectomy or other structural damage sinusitis

Less frequent: Sub-mucosal retropharyngeal dissection Intracranial penetration of nasotracheal tube

(Hall & Shutt, 2002)

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Incidence of accidental intracranial tube placement

3 cases of inadvertent NT tube had been reported 2 associated with fractures of face and base of skull 1 case was routine intubation in a neonate

Accidental intracranial placement of nasogastric tube was reported more frequently with 40 reported cases Speculated possibilities include finer diameter of

tube compared with tracheal tubes

(Paul et al.,2003)

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Incidence of accidental intracranial tube placement

2 reported cases of accidental intracranial placement of foley catheter as of 2003

Occurrence is rare and most likely under reported

Consequences of intracranial tube placement are severe, mortality is as high as 50%

(Paul et al, 2003)

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Complications of intracranial tube placement

Hemiparesis, blindness, loss of the sense of smell, a cerebrospinal fluid fistula

Intracranial inflammation and edema Intracranial bleeding Death

(Sarkari et al., 2012)

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Recommendations for nasotracheal intubations

Insertion should be guided strictly along the floor of the nasal cavity to avoid penetration of the cranial vault.

Dilate the preferred nasal passage with a soft, lubricated rubber nasopharyngeal tube.

Use of phenylephrine spray to constrict nasal vessels Avoid excessive force Is the red robin catheter necessary to guide

placement in adults?

(Paul et al., 2003)(Krebs & Sakai, 2008)

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Red Robin Catheter

Described as a fast, safe, simple technique Technique mostly used in pediatric populations Decreased risk of bleeding with the robin technique Takes longer to perform In a randomized trial study found that in a red robin

catheter guided group there was a significant reduction on obvious nasopharyngeal bleeding 33% verses the softened NETT 10%, however there was significantly more attempts at intubation than the control group

This study was analyzing the pediatric population ages 4-10, ASA I-II

(Elwood et al., 2002)

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Is using the red robin catheter best practice?

Alternatives: Passing a series of nasal airways to dilate the nasal passage,

but this takes time and requires multiple passages increasing the risk of trauma

Covering the distal end of the nasotracheal tube i.e. with the fingertip from a rubber glove however this increases the risk of a misplaced foreign body.

Placing a tube down the lumen of the tube and beyond its tip to help part the tissues for its passage (a suction catheter could be used)

Thermo-softening with warm saline before intubation(Elwood et al., 2002)(Krebs & Sakai 2008)

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Further studies

May be able to show efficacy in the use of red robin catheters in adults.

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Take Home Points

Nasopharyngeal anatomy has the potential to be complicated by unanticipated structural anomalies such as septal deviations, spurs, ulcerations, hypertrophy

Nasotracheal intubation is a frequently used intubating technique that provides uninhibited access to the mouth, but has potential risks including epistaxis as the most common complication, and some more severe such as intracranial NT placement

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Take Home Points

Risk of intracranial tube placement is infrequent however probably under-reported

There are several techniques used in peds and adults including use of a red robin foley catheter

Alternatives are available and should be customized to the patient

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References

Elwood, T., Stillions, D.M., Woo, D.W., Bradford, H.M., Ramamoorthy, C.M. (2002), Nasotracheal Intubation: A randomized trial of two methods. Anesthesiology, 96(1), 51-53.Hall, C. E. J. and Shutt, L. E. (2003), Nasotracheal intubation for head and neck surgery. Anaesthesia, 58: 249–256. Volume 58, Issue 3, pages 249-256, 21 FEB 2003 DOI: 10.1046/j.1365-2044.2003.03034.x

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References

Krebs, M. J., & Sakai, T. (2008). Retropharyngeal dissection during nasotracheal intubation: A rare complication and its management. Journal of Clinical Anesthesia, 20(3), 218-21. Paul, M., Dueck, M., Kampe, S., Petzke, F., & Ladra, A. (2003). Intracranial placement of a nasotracheal tube after transnasal trans sphenoidal surgery. ‐ British journal of anaesthesia, 91(4), 601-604.

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References

Sarkari, A., Tandon, V., Agrawal, D., Mahapatra, A.K. Intracranial foley catheter-Inadvertent

malpositioning in setting of severe craniofacial trauma. Indian Journal of Neurosurgery 2012; 1: 185-86Woo, H. J., Bai, C. H., Song, S. Y., & Kim, Y. D. (2008).

Intracranial placement of a Foley catheter: A rare complication. Otolaryngology--Head and Neck Surgery, 138(1), 115-116.