M&M B.S. cribriform plate perforation: techniques & Management of nasotracheal intubation

1. M&M B.S.cribriform plate perforation:techniques & Management of nasotracheal intubation Lyndsy Morton, BSN, SRNA TMC School of Nurse Anesthesia

2. 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

3. 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

4. Case StudyB.S. • Severe mental retardation directly related to blood-type mismatching as a newborn • Dental caries • Severe periodontitis • Diabetes mellitus • GERD • Allergic rhinitis

5. Pre-op • No known procedure history • No known problems with anesthesia • No ETOH use, no tobacco, no drug use • Labs • Blood glucose 91 • No additional labs • Height/weight/BMI 167cm 77 kg BMI 27 • NKDA

6. 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

7. Pre-op • Review of systems • Airway • Normal neck range of motion • Mallampati Classification: III • Thyromental distance: >3FB • Mouth: Adequate opening, poor dentition • Respiratory • Seasonal allergies • Low risk OSA (male, Age > 50) • Lungs CTA, non-labored, BS equal

8. 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)

9. 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.

10. Anesthetic plan • Pretreatment with neosynephrine 1% nasal spray bilateral nares • Versed 0.5 mg • Pre-oxygenate • Standard propofol induction • Test Ventilate

11. 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

12. 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

13. 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

14. 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

15. 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

16. Intra-op • EBL 50 ml • Final vital signs 13:45 • 115/55, SpO2 100 on RA, HR 60, RR 20, Temp 97.0

17. 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

18. 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.

19. 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.

20. 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

21. 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)

23. Structures forming lateral wall of nasal cavity Path of insertion should be parallel to floor of nasal cavity along the inferior meatus or concha (Hall & Shutt, 2002)

24. Anatomical anomalies • 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 (Hall & Shutt, 2002)

25. 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)

26. 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)

27. 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)

28. 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)

29. 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)

30. 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)

31. 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)

32. Is using the red robin catheter best practice? Alternatives: • Passing a series of nasal airways to dilate the nasal passage, but this takes timeand 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)

33. Further studies • May be able to show efficacy in the use of red robin catheters in adults.

34. 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

35. 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

36. 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

37. 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. 

38. 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: 185-86 Woo, 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.