Learning from Experience – Chapters 6 and 7

Denture as a Foreign Body

Dr. Vasanthi Vidyasagaran^*

Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India

A 65-year-old man, weighing 50 kg presented with severe throat pain, difficulty in talking and swallowing for two days. He gave history of his denture getting displaced while eating and trapped in his throat.

On examination, he was salivating profusely due to his inability to swallow. His lungs were clear, pulse rate was 130 beats/min and BP 140/80 mm Hg. Investigations revealed that he was an undiagnosed diabetic with a random blood sugar of 400 mg. Urine ketones were negative.

CT imaging was done as the foreign body impaction with abscess was suspected and margins needed to be identified. The denture was found embedded in the muscles of the right lateral pharyngeal wall.

As the patient was in too much distress, it was decided to take up the patient under general anaesthesia. Difficult airway trolley including a tracheostomy kit was made available. Inj. Glycopyrrolate 0.2 mg was given. Anaesthesia was induced with Propofol 120 mg and intubated nasally (left nostril) using Succinylcholine 75 mg.

Airway was secured with no great difficulty. Ventilation was adequate and haemodynamics were stable. Mixture of Nitrous Oxide and Oxygen, with 1% Isoflurane was used. Throat was carefully packed with roller gauze soaked in saline. Atracurium, a total of 50 mg, was used for maintenance. His blood glucose was monitored and a bolus of 5 IU rapid acting Insulin and an infusion of 5 IU per hour was started. Hourly blood glucose was monitored.

The surgeons managed to remove the denture using a rigid oesophagoscope. The procedure lasted for about 2 h, as it was quite difficult to get a good hold on the foreign body. One dose of Dexamethasone 8 mg was given. At the end of surgery, the CBG was 189. The patient was reversed. He was observed in the PACU with a T piece for 4 h and then extubated, making sure there was no progressive airway oedema.

Discussion

Some of the concerns in these situations include:

Potential difficult airway – intubation and extubation.
Sepsis and spread of infection into fascial planes.
Possibility of aspiration and post-operative lung infection.
- A good antibiotic cover is required.
Hyperglycaemia and electrolyte imbalance.
Difficult extraction with endoscopy, needing conversion to open surgery.
Option of tracheostomy for emergency situations.
Unanticipated blood loss, which may be difficult to control if it arises from the deep muscles of the pharynx.

Should mask ventilation be done? Mask ventilation is both difficult and risky. Rapid sequence intubation should be preferred.

Why nasal intubation? Surgeons will have more space to operate. Also, the possibility of leaving behind the tube in the post-operative period must be considered knowing that patient tolerance to the nasal tube is better than oral.

Impaction of foreign bodies in oesophagus is not such an uncommon situation. Endoscopic removal of a displaced denture may not be a safe option if the diagnosis is delayed, as they get embedded deep in the pharynx and oesophageal tear may occur.

Modern denture plates do not get displaced easily, but, if they do, locating them may be delayed and difficult as they are radiolucent. There have been clinical reports of such incidents, where the denture had been lodged in the sub glottic area, or the bronchus, and extraction being extremely difficult endangering life of the patient. Serious documented complications include airway obstruction, perforation of the oesophagus, mediastinitis, pneumothorax, pneumopericardium, tracheoesophageal, aortoesophageal and even oesophago-broncho-aortic fistulas, aortic erosion, enterocolonic fistulas and colonic perforation.

Strong evidence exists in favour of using steroids to prevent extubation stridor in cases of foreign body impaction. Steroid therapy should be administered more than 6 h prior to extubation to be effective in reducing airway oedema. The cuff leak test is an adequate test to assess laryngeal oedema (level 2). A leak of greater than 30% of the administered tidal volume upon deflation of the endotracheal tube cuff is safe for successful extubation.

Steroids must be administered specially after multiple attempts at intubation or difficult instrumentation to prevent post-operative laryngeal oedema. Dose of 0.1-0.2â€‰mg/kg IV Dexamethasone is suggested. Exact dose requirement is still controversial.

Use of steroid in diabetic patients? A single dose of Dexamethasone is not an absolute contraindication especially if sugars are being controlled with IV Insulin. The benefits of steroid clearly outweigh the risks involved in its administration to prevent airway oedema.

References

Yadav R, Mahajan G, Mathur RM. Denture plate foreign body of oesophagus. Ind J Thorac Cardiovasc Surg. 2008;24:191-4.
Rathore PK, Raj A, Sayal A, et al. Prolonged foreign body impaction in the oesophagus. Singapore Med J. 2009; 50(2):e53-4.
Firth AL, Moor J, Goodyear PWA. Strachan: Dentures may be radiolucent. Emerg Med J. 2003;20:562-3.
Epstein SK. Corticosteroids to prevent post extubation upper airway obstruction: the evidence mounts. Crit Care. 2007;11(4):156.
Lee CH, Peng MJ, Wu CL. Dexamethasone to prevent post extubation airway obstruction in adults: a prospective, randomized, double-blind, placebo-controlled study. Crit Care. 2007;11(4):R72.

Double Trouble – Haemangioma Tongue and Protruding Maxilla

A 35-year-old woman presented with a haemangioma spread over her lips, tongue and pharynx. She was posted for osteotomy of the maxilla due to inability to close her mouth. She gave history of a previous surgery performed for haemangioma of lip and tongue as a child. She had required tracheostomy at that time and a scar was seen. She requested that a repeat tracheostomy be avoided if possible, Hence, it was decided to try intubation first and resort to tracheostomy if we fail.

Airway examination revealed a diffuse swelling all over her tongue, lips and pharyngeal wall. Small clusters of engorged vessels were also seen hanging from the nasopharynx to the oropharynx. On lying down supine the congestion visibly increased the size of the tongue. She also gave history of awakening from sleep due to tongue swelling. A small gap was present between the uvula and the base of tongue on the right side. She had full range of neck movements, good mouth opening and a clear nasal passage, as revealed by nasal endoscopy.

Patient was first prepared adequately prior to any attempt at securing the airway. The nostril was packed with gauze soaked with 4% Lignocaine with Adrenaline for 5 min and removed. She was then placed in ‘RAMP position’ with a back rest to provide a good 30 degrees head up position to encourage venous drainage and avoid engorgement and tongue swelling. The fibre optic scope was checked and preloaded with size 7.0 endotracheal tube.

Awake fibre optic intubation could not be attempted as the patient was extremely uncooperative. Hence general anaesthesia was induced with Propofol 120 mg and Succinylcholine 75 mg for intubation. Oxygenation with a mask was not difficult. Tongue was held out manually by an assistant using gauze to keep the airway open. It was now feasible to introduce fibre optic bronchoscope without causing damage, through the nostril into the oropharynx and get past the tongue to get reasonable view of the larynx. The endotracheal tube was then passed through the vocal cords and the airway was secured. The throat was then packed using fingers instead of the Magill’s forceps to prevent trauma.

The surgery was completed uneventfully in the head up position. Sclerotherapy to the tongue was administered. Complete neuromuscular recovery was ensured. Dexamethasone 8 mg was given in anticipation of airway oedema. Patient was then kept spontaneously breathing on the nasal tube via T piece and 100% Oxygen, with the tube cuff deflated. Extubation was done after observation for one hour making sure there was no tongue oedema or haematoma obstructing the airway. The patient was in high dependency unit for four hours and then shifted to the ward.

Discussion

Haemangiomas are benign tumours, most commonly located in the head and neck region and occur more frequently in the lips, tongue and palate. The treatment depends upon location of the lesion, size, stage of evolution of the tumour, and the patient’s age. Patient may be on long term oral steroids. The main side effects of high dose steroid therapy in long term are cushingoid features, influence on growth, and susceptibility to serious infections.

Sclerotherapy is successfully utilized in the treatment of these lesions. Pressurized bandage cannot be applied to the region after injection of sclerotic agent in intraoral lesions. Some recurrent haemangiomas may be treated with beta-blockers to reduce angiogenesis. Hence it is important to know what treatment patient is on, during the preoperative visit.

Haemangiomas, in the oral cavity, especially in paediatric population is quite a challenge in more than one way. Awake intubation is not an option in this group of patients. Methods to decompress the lesion in a safe manner, for laryngoscopy and intubation are appropriate positioning, pulling out the tongue, and manual decompression.

Here was a scenario of obvious difficult airway, where it was important to think through the potential problems at every stage of airway management and conduct it efficiently. The options for securing the airway included:

Awake FOB – may be the gold standard; a smooth sleek technique is required to maintain airway and prevent problems. But it is difficult in uncooperative patients and may actually run the risk of vascular injury and bleeding, which can be catastrophic.
General anaesthesia without muscle relaxant – depth of anaesthesia cannot be accurately judged; if patient becomes very deep under GA, upper airway obstruction can get worse due to the huge size of haemangioma and the tongue falling back.; if the patient is under light planes of anaesthesia, any manipulation in the airway may trigger a cough reflex, or laryngeal spasm, making the situation worse.
Rapid sequence intubation.
Tracheostomy.

We used FOB for securing the airway, but only after induction with Propofol and Succinylcholine, and manually holding out the tongue with assistance. The highlight in this case was in fact the help provided by the assistant, who held the tongue out compressing the haemangioma without causing trauma. FOB intubation after general anaesthesia can be tricky and needs plenty of practice. Alternate methods of securing airway must be ready. Extubation is preferably done when the patient is fully awake.

Nasal endotracheal tube is certainly better tolerated than oral tube in an awake patient.

It is of particular importance in this situation where we may have to leave the tube for some time before extubation. Any surgery warrants smooth extubation, but is more relevant during surgery in the airway itself.

References

Hajipour A, Javid MJ, Saedi B. Airway management in a toddler with a giant haemangioma of the tongue. Iran J Pediatr. 2012;22(4):551-4.
Eivazi B, Ardelan M, Baumler W, et al. Update on haemangiomas and vascular malformations of the head and neck. Eur Arch Oto-Rhino-Laryngol. 2009;266(2):187-97.
Van Aalst JA, Bhuller A, Sadove AM. Peadiatric vascular lesions. J Craniofac Surg. 2003;14(4):566-83.

“Nothing can be achieved all by yourself, you need support from various quarters for a successful outcome of any effort”

Learning from Experience – Chapters 6 and 7