Hilmi, Ibtesam A. MB CHB, FRCA; Sullivan, Erin MD; Quinlan, Joseph MD; Shekar, Saraswathy MD
Esophageal perforation is a serious life-threatening injury that may occur during inadvertent esophageal intubation. Early diagnosis of this complication is vital to successful treatment and requires a high index of suspicion because the symptoms are often nonspecific and may be delayed (1). We report two cases of iatrogenic esophageal perforation after attempted endotracheal intubation.
A 55-yr-old woman presented for laparoscopic gastric bypass surgery secondary to morbid obesity. She had a body mass index of 43, a history of obstructive sleep apnea, chronic gastroesophageal reflux disease (GERD), insulin-dependent diabetes, hypertension, and chronic fibromyalgia. Preanesthesia evaluation was unremarkable except for a Class 3 Mallampati airway. General anesthesia was induced with rapid sequence induction and cricoid pressure. The first attempt at tracheal intubation with a Mac 3 laryngoscope blade and endotracheal tube with a stylet resulted in an esophageal intubation, as determined by absence of both breath sounds and carbon dioxide capnographic waveform. When the endotracheal tube was removed, there was blood on the tip. The patient was ventilated via mask to restore oxygen saturation to the normal range. The second attempt at intubation with the gum elastic bougie was successful. During both attempts, only the arytenoid cartilages were visible. Immediately after the first intubation attempt, subcutaneous emphysema was noticed in the neck. As the subcutaneous emphysema progressed, possible injury of the esophagus or the trachea was suspected. A flexible fiberoptic bronchoscopy was performed through the endotracheal tube, and the trachea was evaluated to the level of the carina. Esophageal endoscopy was also performed, revealing a posterior esophageal perforation at a distance of 14 cm from the upper incisors. The remainder of the esophagus was normal with the exception of Barrett mucosa detected at the gastroesophageal junction secondary to chronic GERD.
Soon after the extubation decreased, bilateral breath sounds and continuous oxygen desaturation were noted. Pneumothorax was suspected and confirmed by both aspiration of air after needle insertion in the left second intercostal space and subsequent chest radiograph (Fig. 1). Bilateral pleural pigtail catheters were placed to evacuate the pleural cavities. The procedure was canceled, and the patient was treated with broad-spectrum antibiotics, nasogastric (NG) suction, and total parenteral nutrition and kept nothing by mouth.
Three days later, the patient developed fever, atrial fibrillation, and signs and symptoms of sepsis. A computed tomographic scan of the chest revealed the presence of a right empyema and mediastinitis for which she underwent a right video-assisted thoracoscopic procedure to drain both areas. Postoperatively, the patient was admitted to the intensive care unit (ICU) where she was treated for complications of sepsis and hemodynamic instability. After 4 days in the ICU and 4 wk in the hospital, she was discharged with chronic atrial fibrillation. When she returned a few months later for laparoscopic gastric bypass surgery, her anesthetic and surgical courses were uneventful.
A 79-yr-old woman with a medical history of hypothyroidism and mild dementia presented for cataract extraction under local anesthesia and IV sedation. Her preoperative evaluation was unremarkable except for mild confusion, and her airway examination was reported to be a Mallampati Class 2. The procedure began with topical application of local anesthesia and IV sedation (midazolam 1 mg and fentanyl 25 μg). Approximately 2 h into the procedure, she became agitated and vomited. The anesthesia team decided to continue the procedure under general anesthesia with endotracheal intubation.
The first attempt at endotracheal intubation resulted in an esophageal intubation. The second attempt was performed with a different laryngoscope blade (Miller 2), an endotracheal tube with a stylet, and repositioning the head into a flexed position. None of these measures helped, and esophageal intubation was again attempted. After both attempts, the distal end of the endotracheal tube was covered with blood. The third attempt by a different provider was successful. Only the epiglottis could be visualized during these attempts. The patient was easy to ventilate by mask, and her oxygen saturation was maintained within an acceptable range. The remainder of her anesthetic course was uneventful. The patient emerged from anesthesia without apparent complications. She was admitted to the recovery floor for a few hours during which time she complained of back pain. She was assured by the recovery room nurse that this was caused by lying on a hard table in the operating room (OR), and pain medication was administered. Chest radiograph was performed to check for aspiration because the patient vomited when she had become agitated during IV sedation. The anesthesiologist did not note any abnormalities on the chest radiograph, and the patient was discharged on oral acetaminophen for postoperative pain. At home that evening, the patient’s face started to swell, and she experienced difficulty in breathing. The family called the emergency medical services. She was initially treated for presumed allergic reaction or angioneurotic edema with antihistamine injection and supplemental oxygen via face mask because her oxygen saturation was 80% while breathing room air.
On arrival to the hospital, the patient was in respiratory distress with obvious swelling of her face, neck, and upper chest. An urgent chest radiograph showed bilateral pleural effusions, extensive pneumomediastinum, and subcutaneous emphysema of the neck and upper chest. The review of the immediate postoperative chest radiograph revealed an area of subcutaneous emphysema in the supraclavicular region (Fig. 2), which had not been noted on the initial reading. The patient was taken urgently to the OR to secure a surgical airway via awake tracheostomy under local anesthesia. She was admitted to the ICU. The patient returned to the OR the next day for esophagoscopy, bronchoscopy, exploration of the neck, drainage of mediastinal abscess, and minithoracotomy for drainage of a right pleural collection. The endoscopic examination revealed an esophageal tear in the posterior wall at 18 cm from the upper incisors. The tear led to a large mediastinal collection, and there was also a laceration of the posterior tracheal wall. The mediastinal cavity was débrided, and two drains were left in the cavity. The patient was returned to the ICU to be treated for complications of sepsis, pneumonia, empyema, and hemodynamic instability.
She required multiple surgical procedures to incise and drain the mediastinum and pleural cavity. After 10 days in the ICU, she was discharged to a regular floor to be treated for non–life-threatening complications of infection, esophageal stricture, and tracheostomy. The patient was discharged home after 2 mo in the hospital and 1 mo in the rehabilitation center. She died at home few weeks later from unrelated causes.
The esophagus is a muscular tube 25 cm in length that begins at the level of the cricoid cartilage (at approximately the sixth cervical vertebra), 15 cm from the upper incisors, where it is surrounded by the upper esophageal sphincter. It terminates at the gastroesophageal sphincter 41 cm from the upper incisors. Iatrogenic perforation of the esophagus is a well-documented complication in premature and small birth weight infants after placement of a NG tube or misplaced endotracheal tube (2). In the adult population, perforation of the esophagus during the course of attempted intubation of the trachea is a rare complication or is at least rarely reported.
In a retrospective study published in 1992 (3), 52 transmural esophageal tears were identified over a 15-year period. Iatrogenic causes accounted for most of the injuries (52%), followed by external trauma (23%) and foreign bodies (10%), with 15% of the cases being spontaneous or idiopathic. Most of the injuries involved the thoracic esophagus (28%–54%), followed by the cervical part (20%–40%), whereas injuries of the intraabdominal esophagus were rare (3%–6%). The most common cause of iatrogenic perforation was upper gastrointestinal endoscopy and esophageal dilation, followed by upper abdominal surgery. Only three cases were caused by endotracheal intubation.
The most common sites for cervical esophageal injuries resulting from traumatic or difficult endotracheal intubation are the piriform sinus and the posterior esophageal wall at the tip of the endotracheal tube. The anatomical vulnerability to injury is because of the absence of a reinforcing longitudinal muscle layer in these areas. Furthermore, the use of cricoid pressure and hyperextension of the neck compresses the cervical esophagus against the bodies of the sixth and seventh cervical vertebrae, which increases the risk of injury.
The presence of anatomic deformities of the cervical spine, such as interosseous hyperostosis, kyphosis, or hypertrophic spurs, may be contributing factors for these kinds of injuries (4). In both of the cases reported here, the injury was in the cervical esophagus near the level of the upper esophageal sphincter.
Anterior esophageal wall injury after traumatic endotracheal intubation is not reported. However, one can hypothesize that injury to the anterior esophagus may occur during a difficult endotracheal intubation attempt with a Miller laryngoscope blade and a styletted endotracheal tube configured like a hockey stick. In this circumstance, the force will be directed toward the anterior esophageal wall and possibly result in injury. In the second case report, there was mucosal damage of the anterior esophageal wall because of this particular technique of endotracheal intubation; however, the injury was not serious.
The most significant factors in the mechanism of the injury are the experience of the operator, difficult intubation with multiple attempts, and the use of a rigid stylet (5). Tissue fragility because of chronic GERD, as in the first case, and advanced age, as in the second case, may be contributing factors.
The most common symptom of esophageal injury is pain either in the neck, shoulder, chest, or back (present in both cases). The location and severity of the pain depends on the site and extent of the injury (6). The most common physical finding is subcutaneous emphysema in the neck or upper chest (also present in both cases), especially during positive-pressure mask ventilation, which can force gas between fascial planes into the mediastinum and subcutaneous tissue. The amount of air introduced into the mediastinum is related to the positive-pressure mask ventilation. In the first case, the patient was morbidly obese, and mask ventilation was associated with a large volume of air insufflating the gastrointestinal tract. This made the diagnosis of esophageal injury obvious because of early development of surgical emphysema. In the second case, mask ventilation was easy, and only a small volume of gas entered the esophagus. The resulting amount of surgical emphysema was small and was missed on the first chest radiograph. Dyspnea may be observed with cervical or thoracic esophageal injuries. Fever, sepsis, or shock may be the presenting symptom for perforations diagnosed late after the injury.
Diagnostic methods include plain chest radiograph, which often shows subcutaneous emphysema, pneumothorax, pleural effusion, and pneumomediastinum. However, these findings are dependent on the interval between the incident and the chest radiograph, as well as the site of the perforation and the integrity of the mediastinal pleura, which will determine if pneumothorax will develop (6). Additional diagnostic tools include water-soluble contrast and flexible endoscopy, both of which are essential to establish a definitive diagnosis.
The management of the injury includes the nonsurgical method (antibiotics, total parenteral nutrition, and NG suction) and surgical management (primary repair, drainage, esophageal exclusion, and esophagectomy). The choice of treatment depends on the location, extent of the injury, the time interval between the incident and the diagnosis, the presence of esophageal pathology, presence of sepsis, and the patient’s medical condition. However, controversy continues regarding the optimal treatment of esophageal perforations. In this institution, the preferred method of management of esophageal injuries is still the conservative method (nonsurgical). The surgical intervention is reserved for treatment of complications.
We conclude that esophageal perforation is associated with frequent morbidity and mortality because the anatomical location of the esophagus predisposes patients to the development of fatal mediastinitis and multisystem organ failure. Therefore, a high index of suspicion is required for early diagnosis of this complication. During traumatic intubation, when the possibility of esophageal injury cannot be excluded, urgent endoscopy or water-soluble contrast radiography may be prudent. Our experience confirms that early diagnosis and management (as in our first case) is associated with a more favorable outcome.