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Canadian Journal of Anesthesia 54:322-324 (2007)
© Canadian Anesthesiologists' Society, 2007

Correspondence

Another complication associated with videolaryngoscopy

Michael K.F. Choo, MBChB BMedSci, Vincent S.T. Yeo, MBBS MMed and Jee Jian See, MBBS MMed

Tan Tock Seng Hospital, Singapore, E-mail: mkfchoo{at}yahoo.co.nz

To the Editor:

We were interested to read the first report of complications arising from routine use of the Glidescope® videolaryngoscope (GVL)1 and describe a similar complication associated with the device. A 62-yr-old female presented for right ureteroscopy for renal stone treatment under general anaesthesia. A 7.5-mm internal diameter cuffed endotracheal tube (ETT) was used for intubation with the GVL. After uncomplicated induction of anesthesia, a standard midline approach with the GVL was used, and a stylet facilitated tracheal intubation. Other than encountering slight resistance as the ETT passed the laryngeal inlet, the remainder of the intubation sequence was unremarkable. Of special note, no resistance was encountered while passing the ETT into the oropharyngeal cavity.

However, at the end of the case, it was discovered that the ETT had perforated the right palatopharyngeal fold (FigureGo). An otorhinolaryngologist was consulted and hemostasis was established with electrocautery; there was minimal bleeding. Thereafter, residual neuromuscular block was reversed, the patient was allowed to awaken while breathing 100% oxygen, and her trachea was extubated. The patient experienced a sore throat postoperatively, but had an uneventful recovery. She remained in hospital overnight for observation, and was discharged the following day with no sequalae. At outpatient follow-up six weeks later, good wound healing of the palatopharyngeal laceration was observed, and throat discomfort had fully resolved.


Figure 1
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  		FIGURE Oropharyngeal view under anesthesia with a tonsillectomy gag in situ. The original endotracheal tube was removed and the patient’s trachea was re-intubated. The forceps reveal a false mucosal tract through the right palatopharyngeal fold.

 
While advantages of GVL have been well demonstrated, 2,3 there is an inherent risk of trauma to the pharyngeal mucosa, as with any airway device. As highlighted by Cooper,1 a potential blind spot exists at the point where the operator looses sight of the ETT tip at the back of the pharynx, until it resurfaces within the camera’s visual field at the laryngeal inlet. The extent of the blind spot is very patient-dependent. We suspect that the pharyngeal mucosa of this patient was injured during ETT passage through this blind spot. This suggests the need for operator vigilance in viewing the tip of the ETT as it advances into the pharynx without causing any trauma. The operator should also examine the ETT as it ‘resurfaces’ to see if there are any blood, as possible evidence of trauma to the mucosal tissues. Another refinement might be to insert the ETT with the tip facing against the blade of the GVL. Once it is visualized on the monitor, the ETT can then be redirected with stylet in situ. This would be different from Cuchillo et al.’s technique of turning whilst inserting the ETT.4 Passing the tube from the lateral side of the patient’s mouth should also be avoided, as the palatopharyngeal fold may be taught. However, this technique has been suggested by others for tracheal intubation.5

In conclusion, complications for the GVL, while rare, are now being reported. Such complications mandate vigilance on the part of the anesthesiologist while the ETT is advanced, with consideration of preventive maneuvers as described.

Footnotes

Accepted for publication December 21, 2006.

References

1 Cooper RM. Complications associated with the use of the GlideScope® videolaryngoscope. Can J Anesth 2007; 54: 54–7.[Abstract/Free Full Text]

2 Sun DA, Warriner CB, Parsons DG, Klein R, Umedaly HS, Moult M. The GlideScope® Video Laryngoscope: randomized clinical trial in 200 patients. Br J Anaesth 2005; 94: 381–4.[Abstract/Free Full Text]

3 Lim TJ, Lim Y, Liu EH. Evaluation of ease of intubation with the GlideScope® or Macintosh laryngoscope by anaesthetists in simulated easy and difficult laryngoscopy. Anaesthesia 2005; 60: 180–3.[Medline]

4 Cuchillo JV, Rodriguez MA. Considerations aimed at facilitating the use of the new GlideScope® videolaryngoscope (Letter). Can J Anesth 2005; 52: 661.[Free Full Text]

5 Doyle DJ, Ramachandran M, Zura A, Ryckman JV, Abdelmalak B. The Glidescope video laryngoscope: clinical experience in 747 cases. Anesthesiology 2005; 103: A842 (abstract).




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