|Year : 2014 | Volume
| Issue : 2 | Page : 91-94
Retrograde intubation in a complicated bilateral mandibular fracture from gunshot injury
Orilonise O Olatunji
Department of Anaesthesia, Ekiti State University, and Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti-State, Nigeria
|Date of Web Publication||16-Mar-2015|
Orilonise O Olatunji
Department of Anaesthesia, Ekiti State University, P.M.B. 5363, Ado-Ekiti, Ekiti-State, Nigeria, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti-State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Endotracheal intubation is one of the most important anaesthetic skills. Endotracheal intubation in patients with limited mouth opening always remains a challenge, especially in the absence of a flexible fiber-optic bronchoscope. The retrograde catheter technique is an acceptable option for airway management in cases where oral intubation is not possible because of limited mouth opening, or is not recommended because of fear of dislodgement of fracture segments of facial bones. We performed retrograde intubation in a complicated bilateral mandibular fracture from a gunshot injury.
Keywords: Halothane anaesthesia, limited mouth opening, nasal intubation, retrograde
|How to cite this article:|
Olatunji OO. Retrograde intubation in a complicated bilateral mandibular fracture from gunshot injury. Ann Nigerian Med 2014;8:91-4
| Introduction|| |
The retrograde tracheal intubation is an acceptable option for airway management in cases where oral intubation by direct laryngoscopy is difficult or technically impossible.
This technique is feasible in the presence of blood or secretions in the upper airway.  It is an alternative to cricothyroidotomy in emergency airway management (rescue techniques).  Flexible fiberoptic laryngoscopy is the method of choice for the management of anticipated difficult tracheal intubation, a leading cause of catastrophic outcomes in anaesthesia practice. 
| Case Report|| |
A 51-year-old farmer presented with a comminuted fracture of the entire mandibular associated with limited mouth opening; following a gunshot injury. He was planned for an elective mandibular reconstruction with iliac bone graft, 2 months after an initial damage control surgery.
Preoperative assessment revealed a middle-aged man, American Society of Anaesthesiologist physical status 11, mildly pale, malnourished, with facial asymmetry, limited mouth opening (from fibrosis/scar tissue), receding chin, and dental malocclusion. He had a thyromental distance of 4 cm and mouth opening of 2 cm. Respiratory and cardiovascular systems were found to be normal on examination. Consent for anaesthesia was obtained from the patient.
During preinduction, intravenous access was secured with an 18 G cannula, and 500 mls of normal saline was infused. A difficult airway tray was assembled, which included a cook retrograde intubation set. Standard monitoring and baseline measurement of vital signs including noninvasive blood pressure, heart rate, electrocardiogram, and pulse oxymetry, were recorded.
Induction and airway management: After preoxygenation, anaesthesia was induced with halothane in 100% oxygen; with progressive increases in halothane concentration, from 1% to 3%.
Blind nasal intubation was tried after achieving adequate depth of anaesthesia. This was carried out with a 7 mm polyvinyl chloride cuffed tube, because conventional laryngoscopy was predictably difficult. We decided to proceed with retrograde nasotracheal intubation after two failed attempts at blind nasal intubation, as a tracheostomy tube and a fiber-optic bronchoscope were not readily available.
The cricothyroid membrane was pierced with an 18G needle/cannula assembly [Figure 1], attached to a 5-ml syringe-containing saline, for aspiration test. The needle was withdrawn, and the guide wire was passed through the cannula in the cephalic direction [Figure 2]. The wire was retrieved from the mouth with the aid of a Magill forceps [Figure 3]. A size 7.0 polyvinyl chloride endotracheal tube (ETT) was passed through the nostril as a conduit for a size 1 silk suture, which was also retrieved from the mouth with the aid of a Magill forceps [Figure 3].
|Figure 2: Threading the j-guide wire in the sub-glottic area, in the cephalic direction|
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|Figure 3: Magill forceps used to retrieve, the guide-wire and silk thread (loaded on the endotracheal tube)|
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The silk suture was tied to the intraoral portion of the guide wire, and the extra nasal portion of the suture was now used to advance the wire through the lumen of the size 7.0 ETT, and out of the nostril [Figure 4]. The 7.0 ETT was subsequently removed. The guide wire was then used to railroad a lubricated size 7.5 ETT (which was subsequently used for anaesthesia) through the nostril into the trachea. The black teflon catheter was introduced through the ETT [Figure 5], and was used to provide extra stiffness for railroading the ETT into the mid-trachea, after the removal of the guide-wire.
|Figure 4: The extral-nasal knot connecting the guide wire and the silk thread|
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Finally, the Teflon introducer was removed, and the patient was connected to the anaesthesia breathing system [Figure 6], and confirmation of correct placement of ETT done clinically by auscultation for breath sounds, and observation of the reservoir bag movements with spontaneous ventilation. We administered a balanced general anaesthesia with controlled ventilation using halothane, pancuronium and pethidine. Observation and measurements of vital signs were continued every 5 mins, till the end of surgery.
|Figure 5: The tefl on catheter being maneuvered into the trachea, via the endotracheal tube|
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|Figure 6: The endotracheal tube, being connected to the anaesthesia breathing system, after intubation|
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| Discussion|| |
In the absence of a fibre-optic bronchoscope, the techniques for endotracheal intubation in patients with limited mouth opening include blind nasal intubation, retrograde intubation, and the time-tested tracheostomy. Due to the frequently associated airway anomaly, failure of blind nasal intubation is not uncommon. 
The technique of retrograde intubation was originally described by Butler and Cirillo in 1960. 
There have been several modifications of this technique throughout these years. 
In adults, this can be done in the anesthetized or a conscious patient (with preprocedure airway topical or regional anaesthesia). In adults, cricothyroid puncture can be done with a long arm central venous catheter or epidural catheter passed through the accompanying needle.  A customized kit for this procedure, is the cook's retrograde intubation kit (containing a stiff j-wire) which was used in the management of our patient. 
We passed the Teflon catheter separately and beyond the guide wire, because its stiffness was adjudged sufficient to guide the ETT into the mid trachea, even after removal of the guide wire [Figure 4] and [Figure 5]; instead of passing the Teflon catheter over the guide wire as recommended by Gal.  The tip of the tube may be caught on the anterior commissure, and therefore not pass through (into the trachea).
Our ETT passed successfully at the very first attempt, and this confirms the findings of Weksler et al. that retrograde intubation is a minimally invasive airway management technique, with a flat learning curve and a high level of skill retention.  For nasotracheal intubation using this technique, the catheter is first retrieved through the mouth and later pulled through the nose with another catheter.  We used nasally passed size 1 silk suture instead of another catheter to pull up the guide-wire. If there is some mouth opening as in the case of this patient, the guide wire can be retrieved from the mouth with the help of a finger, a Magill forceps, or a suction catheter. ,,
Fluoroscopic guidance with X-ray and a pharyngeal loop may be used to facilitate the nasal retrieval of the guide-wire from the oropharynx during retrograde tracheal intubation in such patients. ,
Flexible fiber-optic bronchoscope, which is the preferred option for difficult tracheal intubation, may not be available in resource poor settings due to the initial high cost, as well as its maintenance. 
The complications we experienced were a brief period of hypoxemia shortly before securing the airway, bradycardia, and bleeding at the point of the cricothyroid puncture, and these are some of the common complications. Other documented complications include sore throat, laryngospasm bronchospasm, hematoma, tube misplacement, and epistaxis. Rarer complications include laryngeal fracture with permanent dystonia, subcutaneous emphysema, pneumomediastinum, infection, bleeding, and retained wire. ,, our patient recovered fully within 3 weeks.
| Conclusion|| |
In the absence of a fiber-optic bronchoscope, and when blind nasal intubation fails or tracheostomy is not immediately possible, retrograde intubation using a guide-wire is a feasible and safe alternative for airway management in patients with limited mouth opening.
| Acknowledgment|| |
My immense gratitude goes to DR. OBITADE OBIMAKINDE (EKSU), who assisted in recording the images.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]