Anesthesia: Essays and Researches; 6(1); Jan-Jun 2012
Letters
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Figure 3: Artificial dentures for missing teeth
gland, middle ear deafness, heart defects, hypospadias,
short stature and mental retardation.[1]
Anesthetic considerations include a detailed history
to confirm the diagnosis, rule out any anesthetic
complication (such as difficult mask ventilation or
intubation) in any previous surgery. These patients
might have a difficult airway due to facial anomalies,
brachycephaly and maxillary hypoplasia. Therefore
a detailed airway examination is mandatory along
with preparation of the difficulty airway cart in the
operation theatre. A complete cardiovascular workup
to rule out congenital cardiac anomalies such as
interatrial septal defects, semilunar valve stenosis or
insufficiencies is advocated.[7] These patients might
also have communicating hydrocephalus, psychomotor
retardation or hypotonia. So preoperative councelling
and maintenance of ICP (intra cranial pressure) in the
perioperative period is required.
To conclude ARS is a rare disorder with great genetic and
morphologic variability. The concomitant occurrence of
dental, craniofacial and cardiovascular anomalies can be
quiet challenging even to an experienced anesthesiologist.
Though EUA is a short procedure and does not require
endotracheal intubation in most of the cases, an
exhaustive and meticulous physical examination can
Intraoperative desaturation during thyroidectomy. Can
endotracheal tube migration still be a cause?
Sir,
Intraoperative displacement of endotracheal tube (ET)
can result in serious complications such as accidental
extubation or endobronchial intubation.[1] Early
recognition and repositioning of the ET are important.
avoid any catastrophe occurring during the perioperative
period, especially due to difficult airway.
ACKNOWLEDGMENT
The Author would like to thank the patient for providing
consent to use her photograph in this article.
Neha Baduni, Maitree Pandey,
Manoj Kumar Sanwal, Meenakshi Verma
Department of Anaestheiology and Intensive Care,
Lady Hardinge Medical College and Associated Hospitals,
New Delhi, India
Corresponding author:
Dr. Neha Baduni,
GH 12/183, Paschim Vihar,
New Delhi, India.
E-mail: baduni.neha@gmail.com
REFERENCES
1. Shields MB, Buckley E, Klintworth GK,Thresher R.Axenfeld-Rieger syndrome.
A spectrum of developmental disorders. Surv Ophthalmol 1985;29:387-409.
2. Childers NK, Wright JT. Dental and craniofacial anomalies of Axenfeld- Rieger
syndrome. J Oral Pathol 1986;15:534-9.
3. Dressler P, Gramer E. Morphologie, familienanamnese und
diagnosezeitpunkt bei 26 patienten mit Axenfeld-Rieger-syndrom und
glaukom oder okulärer hypertension. Ophthalmologe 2006;103:393-400.
4. Axenfeld T. Embryotoxon corneae posterius. Ber Dtsch Ophthalmol Ges
1920;42:301-2.
5. Semina EV, Reiter R, Leysens NJ, Alward WL, Small KW, Datson NA, et  al.
Cloning and characterization of a novel bicoid-related homeobox transcription
factor gene, RIEG, involved in Rieger syndrome. Nat Genet 1996;14:392-9.
6. Mears AJ, Jordan T, Mirzayans F, Dubois S, Kume T, Parlee M, et al. Mutations
of the forkhead/winged-helix gene, FKHL7, in patients with Axenfeld–Rieger
anomaly. Am J Hum Genet 1998;63:1316-28.
7. Gross S, Farnetani MA, Berardi R,Vivarelli R,Vanni M, Morgese G, et al. Familial
Axenfeld-Rieger anomaly, cardiac malformations, and sensorineural hearing loss:
A provisionally unique genetic syndrome? Am J Med Genet 2002;111:182-6.
Access this article online
Website DOI Quick Response Code
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Most of the existing case reports mention ET displacement
during change in patient position or during laparoscopic
surgeries[1] or during echocardiography probe placement. [2]
We report a case of endobronchial migration of ET
following mobilization of a large multinodular goiter.
109
 Anesthesia: Essays and Researches; 6(1); Jan-Jun 2012 Letters
A 45-year-old lady with a body mass index of 30 kg/m2
was diagnosed to have multinodular goiter was posted
for subtotal thyroidectomy. General physical and systemic
examination including airway were normal. Thyroid
function tests were normal. Indirect laryngoscopy was a
normal study with bilateral mobile vocal cords. Radiologic
examination of neck revealed a significant tracheal shift
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of 1.5 cm to the left side [Figure 1].
A written informed consent was obtained for surgery
and anesthesia. After adequate nil per oral status patient
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was scheduled for surgery. A 16 gauge intravenous (IV)
line was secured. Preinduction monitors included
electrocardiogram, pulse-oximetry, and noninvasive blood
pressure. After adequate preoxygenation, anesthesia was
induced with I.V propofol 150 mg and fentanyl 125 µg.
After loss of verbal contact, ability to mask ventilate
was confirmed. Muscle paralysis was obtained with IV
vecuronium 7 mg and airway was secured with 7.0 mm
cuffed oral endotracheal tube. Bilateral air entry confirmed
by auscultation over the chest and tube was fixed at
20 cm at the incisor level. Maintenance of anesthesia
was with oxygen and nitrous oxide (40:60) with 1–1.5%
isoflurane. Postinduction end tidal carbon-di-oxide (EtCO2)
monitor was used. Patient was positioned for thyroid
surgery with extension of the neck and a pillow under the
shoulder. The tube position was reconfirmed and surgery
proceeded.
Initial intraoperative period was uneventful. Once the
thyroid gland was mobilized and removed there was
a sudden increase in airway pressure from 22 cm H2O
to 38 cm H2O. Oxygen saturation (SpO2) dropped to
85% and EtCO2 showed a slight fall to 30 mmHg from
38 mmHg. On auscultation, it was noticed that there was
absent air entry on the left side of the chest. A possible
diagnosis of endobronchial tube migration was made. The
Figure 1: Radiograph of neck and chest showing gross deviation of trachea
to the left by 2 cm
110
ET was withdrawn by 2 cm and bilateral air entry was
reconfirmed. The tube was refixed at 18 cm. With this
change, the peak airway pressures returned to normal and
oxygen saturation improved to 100%. Rest of the surgery
and extubation was uneventful.
Positioning for a thyroid surgery involves extension of
the head and neck with a pillow under the shoulder
to facilitate good surgical exposure. This position
involves the theoretical risk of migration of ET
outwards that can sometimes even result in accidental
extubation.
In our case, there was a tracheal deviation of about 1.5
to 2 cm from the midline due to the enlarged thyroid
gland [Figure 1]. On excision of the thyroid gland, the
tracheal deviation was corrected that was evident in the
postoperative neck radiograph. This centralization of
trachea would have resulted in the tube tip to migrate
endobronchial.
The sudden increase in airway pressure and drop in
oxygen saturation after removal of the gland along with
absent breath sounds on the left side of the chest can
be explained by endobronchial migration of the tube that
would have probably been secured just above the carina
after intubation.
Anesthesiologists have to be aware of this possible cause
for endo tracheal tube migration especially in surgeries
on the thyroid gland.
Rohith Krishna,
Madagondapalli Srinivasan Nataraj
Department of Anaesthesiology, Kasturba Medical College,
Manipal, India
Correspondence author:
Dr. Rohith Krishna,
Assistant Professor, Department of Anaesthesiology,
Kasturba Medical College, Manipal - 576 104, India.
E-mail: rohithi22@yahoo.co.in
REFERENCES
1. Nishikawa K, Nagashima C, Shimodate Y, Lgarashi M, Maniki A. Migration of
the endotracheal tube during laparoscopy-assiated abdominal surgery in
young and elderly patients. Can J Anaesth 2004;51:1053-4.
2. Neema PK, Manikandan S, Rathod RC. Endotracheal tube migration
following transoesophageal echocardiography probe placement in a child.
Eur J Anaesthesiol 2006;23:1060-1.
Access this article online
Website DOI Quick Response Code
www.aeronline.org 10.4103/0259-1162.103394