Article, Otolaryngology

Middle turbinectomy as a complication of nasopharyngeal airway placement

Case Report

Middle turbinectomy as a complication of nasopharyngeal airway placement

Abstract

A nasopharyngeal airway is an adjunct used to relieve airway obstruction due to tongue relaxation in an unconscious or semiconscious patient. It is considered a safe procedure in patients without massive facial trauma or basilar Skull fracture. This is a report of a healthy patient undergoing procedural sedation who sustained a middle turbinectomy upon placement of a nasal trumpet to assist ventilation. He subsequently developed severe epistaxis that resolved only after multiple attempts of packing both by the emergency physician as well as the otolaryngology service. It is to be hoped that this will increase awareness among emergency physicians of this unusual complication.

This is a 58-year-old gentleman with a history of Essential hypertension who was referred from the clinic for manage- ment of tachycardia. The patient noted a 1-day history of Chest tightness and sensation that his heart was pounding. There were no precipitating factors, modifying factors, or associated symptoms. On examination, the patient was noted to have a tachycardia of 169 beats per minute with otherwise normal vitals. His physical examination was notable only for tachycardia. Electrocardiogram showed a Narrow complex tachycardia at a rate of 166. Adenosine was given that revealed the rhythm to be atrial flutter. After consultation with the patient, the decision for cardioversion was made. Procedural sedation was performed using propofol and fentanyl. The patient was easily converted to sinus rhythm with a single shock of 50 J (biphasic). Shortly after the cardioversion, the patient became apneic and cyanotic, and oxygen saturations dropped to 72%. Ventilation was assisted using bag valve mask and a nasopharyngeal airway was placed without difficulty. Within 1 to 2 minutes, the patient began breathing spontaneously. Complete blood count, chem-7, and troponin-I all returned normal. Metoprolol was started in consultation with cardiology.

After a 1-hour period of observation, the patient was ready for discharge with close follow-up. He was

receiving his discharge instructions when he began bleeding briskly from the left nare in which the nasopharyngeal airway had been placed. This did not resolve with standard nose-pinching pressure and oxyme- tolazone nasal spray. The nare was packed with a 5.5 cm Rapid Rhino (ArthroCare UK Ltd, Glenfield Leicester- shire, UK). Bleeding continued from the nose and also from the left lacrimal duct. The packing was then replaced with a 7.5 cm Rapid Rhino without any improvement. At this time, the nasopharyngeal airway (now in the garbage) was inspected, and a firm piece of tissue approximately 3 cm in length was found protruding from the tip of it (Fig. 1). It was quickly determined that this was likely a nasal turbinate. The otolaryngology service was consulted and placed 2 Merocel packings (Medtronic Xomed, Jacksonville, FL) with eventual cessation of the patient’s epistaxis. The patient was admitted for overnight observa- tion. At follow-up, 5 days later, the packing was removed and nasal endoscopy showed the middle turbinate to be nearly completely absent.

Nasopharyngeal airways (nasal trumpets) are proven useful adjuncts to assist ventilation of patients who have airway obstruction due to tongue relaxation. They are particularly helpful in patients with tongue obstruction who are semiconscious and would otherwise gag from orophar- yngeal airway placement.

Turbinate injury after Nasotracheal intubation has been described in several case reports previously [1-5]. On the other hand, this complication after nasopharyngeal airway insertion has been reported only once [6]. Placing a nasal trumpet is generally considered a benign procedure with occasional epistaxis as the most common complication. Generally, they are placed in an unconscious or semicon- scious patient with acute airway obstruction. Because of this urgency, hemostatic agents such as phenylephrine or oxymetolazone are not routinely used. The airway is advanced posteriorly with its tip oriented along the floor or septum. Lubricating gel can help facilitate its movement past dry mucosa. These devices should be avoided in patients with basilar Skull fractures or severe facial trauma. Turbinectomy as a complication is rare and should generally lead to little long-term morbidity. This case serves as a reminder that no procedure is without risk. However, in

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513.e4 Case Report

Michael Zwank MD Regions Hospital, St Paul, Minn, USA University of Minnesota, Minn, USA

E-mail address: [email protected] doi:10.1016/j.ajem.2008.09.038

References

Fig. 1 Nasopharyneal airway with avulsed turbinate.

the appropriate setting, the benefit of reduced airway obstruction far outweighs the risk of turbinate trauma.

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