No significant bleeding was reported by her parents since the time of the injury. Of note, she initially presented to an outside hospital, where an uncontrasted CT scan of the neck showed the needle entering the left retromolar trigone, traversing the pterygoid muscle, and extending to the infratemporal fossa. It also demonstrated close proximity to the external carotid artery without any noticeable vascular injury. A surgeon at the outside hospital attempted to manually remove the needle but was unsuccessful. The patient was subsequently transferred to our institution for further management. On arrival, she was noted to be alert, tearful, and drooling copiously, but breathing comfortably without obstruction. She exhibited limited mouth opening and resisted any examination of her oral cavity. A long plastic sewing needle was clearly visible extruding diagonally from the left side of the patient’s oral cavity (Figure 3).
The surgical team assessed the child and decided that a CT angiography (CTA) of the neck with contrast was necessary to further delineate the vascular structures before surgical manipulation. Of primary concern was the potential for massive hemorrhage after movement or removal of the foreign body. Together with the anesthesia team, the decision was made to secure the patient’s airway in the operating room (OR) before CT scan in an attempt to prevent unexpected loss of the airway during scanning.
In the preinduction area, the anesthesia care team planned for premedication with intravenous (IV) midazolam and glycopyrrolate; however, the patient’s peripheral IV catheter was noted to be infiltrated on initial attempt to bolus medication. The child responded by becoming highly anxious and agitated. The consensus was that attempting venous access in this child would risk sudden movements that could cause disturbance of the needle and possible acute decompensation. Therefore, sedating the child was deemed necessary before re-establishing venous access. To obtain sedation, 50 mg (3 mg/kg) intramuscular racemic ketamine was administered while the patient was in her father’s arms. After approximately 5 minutes, she appeared calm and sedated and was breathing well without signs of obstruction. The patient was transported to the OR with a pulse oximeter in place. On arrival, American Society of Anesthesiologists monitors were established with both the attending anesthesiologist and the attending surgeon present.
Induction of Anesthesia
Before ketamine administration, equipment was checked, including a pediatric rigid bronchoscope, a flexible fiberoptic intubating bronchoscope, and a tracheostomy tray. The induction goals were verified between the teams, and they included maintaining spontaneous ventilation, ensuring hemodynamic stability, and securing the patient’s airway without disturbing the foreign body. In addition, 2 units of uncross-matched O-negative blood were ordered from the blood bank. The possibility of cutting the extraoral portion of the needle was discussed, but not attempted because of possible needle tip movement, which could precipitate bleeding.
The anesthesiologist placed a lubricated uncuffed 3.0-mm endotracheal tube (ETT) through the patient’s right nasal passage into the posterior pharynx to serve as a nasopharyngeal airway. This was connected to the anesthesia circuit, and the child received a mixture of nitrous oxide 4 L/min and oxygen 2 L/min while breathing spontaneously. A 22-gauge peripheral IV catheter was placed in her left hand and an 18-gauge peripheral IV catheter in her left saphenous vein. A blood sample was drawn for cross-match, and 2 units of packed red blood cells were ordered emergently. Then, 0.2 mg glycopyrrolate and 4 μg dexmedetomidine were given intravenously. The child continued to breathe spontaneously and, to deepen anesthesia, a propofol infusion at 125 μg/kg/min was initiated. In addition, sevoflurane was added and gradually increased to 5% inspired concentration. A 4.5-mm cuffed ETT was then placed through the left nasal passage. With the child breathing spontaneously, the ear, nose, and throat surgeon passed a flexible fiberoptic scope through the 4.5-mm tube into the nasopharynx. When the vocal cords were visualized, 2 mL of 2% lidocaine was injected through the scope directed at the larynx. The scope was then advanced into the trachea and down to the carina. At this point, the ETT was advanced over the scope into the trachea. After ensuring successful placement by fiberoptic visualization, the scope was removed and the circuit was connected to the nasotracheal tube (Figure 4).
After confirming end-tidal CO2 and bilateral chest rise, the left nasotracheal tube was secured. Intubation was achieved without apnea, breathholding, or coughing. The right-sided nasal airway was then removed. Before transport, the patient received 10 mg IV rocuronium and was transitioned to appropriate transport monitors. She was accompanied to the CT scanner by the anesthesia care team and the surgical team.
The patient was transported to the CT scanner and back to the OR without complication. She remained hemodynamically stable throughout. A propofol infusion was used for the maintenance of anesthesia during transport, and the patient was hand-ventilated.
CTA neck findings included a tubular, partially hollow radio-opaque foreign body within the oral cavity penetrating the mucosa of the left oral cavity just medial to the retromolar trigone with the tip terminating just beyond the posterior margin of the left medial pterygoid muscle. The tip was just medial to the left mandibular ramus and approximately 0.5 cm anterior to the mandibular portion of the left maxillary artery (Figure 5). The internal carotid artery and jugular vein appeared patent. The contralateral vessels appeared unremarkable. The remainder of the oropharynx, nasopharynx, larynx, and hypopharynx was unremarkable.
Foreign Body Removal
On return to the OR, propofol was discontinued, and maintenance of anesthesia was achieved with approximately 1.0 minimum alveolar concentration sevoflurane. The attending surgeon performed a soft tissue exposure, and the foreign body was successfully removed without complication (Figure 6). It should be noted that the patient’s parents were counseled on the possible need for emergent left neck exploration versus packing of the oral cavity and oropharynx with angiography and embolization if life-threatening bleeding was encountered.
The patient received 4 mg dexamethasone and 2 mg ondansetron. Her neuromuscular blockade was reversed with 0.75 mg neostigmine along with administration of 0.15 mg glycopyrrolate. After meeting extubation criteria, she was uneventfully extubated.
The patient experienced no perioperative complications. A repeat CTA on postoperative day 1 showed interval removal of the nasotracheal tube and foreign body with no evidence of vascular injury. The patient was discharged home in good condition on postoperative day 1.
In summary, we have described the management of a child with an unusual airway foreign body that posed 2 life-threatening challenges. The foreign body presented a physical obstruction preventing any form of mask ventilation, and its proximity to major vessels introduced the possibility of significant hemorrhage further complicating airway management. These features made our experience unique from both an anesthesia and a surgical perspective.
Loss of Venous Access
The initial plan for induction of anesthesia—reliance on incremental dosing of IV anesthetic agents with the maintenance of spontaneous respiration—was hindered by the unanticipated loss of peripheral venous access. Moreover, venous access was especially important given our concern for potential massive hemorrhage during airway manipulation. The team’s focus became successful peripheral IV catheter placement in a calm, sedated child breathing spontaneously. Intramuscular ketamine was the ideal drug to achieve this. Alternative options for sedation include intranasal midazolam or fentanyl, or rectal barbiturate, but intramuscular ketamine was chosen because of less dose–response variability. Patterson1 reports successful use of ketamine as the sole agent for intubation of a 10-year-old boy impaled with a toothbrush, and they similarly avoided any airway complications.
Once initial sedation had been achieved by intramuscular ketamine, we inserted a 3.0-mm ETT through the right nasal passage, which allowed for the delivery of oxygen and nitrous oxide to maintain sedation while venous access was obtained. This nasopharyngeal airway also circumvented the necessity for a face mask to deepen anesthesia with sevoflurane. We augmented sedation with intermittent aliquots of dexmedetomidine plus a low-dose propofol infusion to minimize airway reactivity without abolishing the patient’s spontaneous respiratory effort.
Lack of Option to Ventilate
The majority of airway foreign bodies described in the pediatric literature are confined to the midairways and especially lower airways in children who have survived transport to the hospital, but no consensus is reached in the literature pointing to superiority of spontaneous versus controlled ventilation.2 In that population, mask ventilation is usually an option if the patient becomes apneic. What makes this case unique and more challenging is the elimination of mask ventilation as a possibility.
The inability to bag–mask ventilate or use a supraglottic device because of the protruding foreign body eliminated a major pathway of the American Society of Anesthesiologists difficult airway algorithm.3 There is a paucity of literature describing traumatic penetration to the oropharyngeal cavity, but in those reports, awake fiberoptic intubation is the primary method identified for airway management.4–6 However, awake intubation was not a feasible option for our patient because of her age and inability to reliably cooperate.
Before the patient’s arrival in the OR, a pediatric rigid bronchoscope, a flexible fiberoptic intubating bronchoscope, ETTs of various shapes and sizes, and a tracheostomy tray were set up as backup equipment. Once a sufficiently deep plane of anesthesia was achieved, the surgeon fiberoptically intubated the trachea through the nasal passage, which allowed the attending anesthesiologist to maintain primary focus on anesthetic depth and hemodynamic control. Placement of the ETT was accomplished on the first attempt without complication. The patient maintained spontaneous ventilation from initiation of sedation through confirmation of nasotracheal tube placement by the use of low doses of drugs that tend to preserve spontaneous ventilation (racemic ketamine and dexmedetomidine) in conjunction with the incremental use of propofol and sevoflurane.
A CTA of the neck with contrast before surgical manipulation of the sewing needle was necessary to delineate nearby vasculature. Importantly, the sensitivity of CTA for detecting vascular injury is <100%; according to a retrospective evaluation of 53 sets of angiograms from patients with penetrating neck injuries, sensitivity of CTA for detecting arterial injury ranged from 75.7% to 82.2% with 96.4% to 98.4% specificity.7 Therefore, negative findings were certainly reassuring, but did not eliminate the possibility of vascular compromise. Our team had 3 priorities in preparation for potential bleeding: having packed red blood cells available in the OR, avoiding inadvertent needle dislodgement, and identifying needle location by further imaging. Before attempting airway manipulation, we sent a blood sample to the laboratory and ordered 2 units of packed red blood cells emergently.
We have described the successful anesthetic and surgical management of a patient with a penetrating oropharyngeal body that precluded the traditional methods of airway control. The utility of intramuscular ketamine and the judicious use of a combination of inhaled and IV agents succeeded in maintaining spontaneous respiration while providing optimal conditions for venous access and fiberoptic nasal intubation. In view of the potential for significant hemorrhage complicating airway management, we also highlighted the importance of being prepared with venous access and blood products before securing or manipulating the airway.
1. Patterson NA. Management of an unusual pediatric difficult airway using ketamine as a sole agent. Pediatric Anesthesia. 2008;18:785788.
2. Fidkowski CW, Zheng H, Firth PG. The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases. Anesth Analg. 2010;111:10161025.
3. Apfelbaum JL, Hagberg CA, Caplan RA, et al.; American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118:251270.
4. Gupta B, Kaur M, Sawhney C, D’souza N. Impacted toothbrush in the oropharynx: a challenging airway. Paediatr Anaesth. 2010;20:964966.
5. Ng KF, Lo CF. The bamboo skewer: airway management in a patient with penetrating injury of the floor of mouth. Can J Anaesth. 1996;43:11561160.
6. Dobson GT. Airway management in a patient with a nail-gun injury to the floor of the mouth. Ulster Med J. 2000;69:148151.
Copyright © 2016 International Anesthesia Research Society
7. Bodanapally UK, Dreizin D, Sliker CW, Boscak AR, Reddy RP. Vascular injuries to the neck after penetrating trauma: diagnostic performance of 40- and 64-MDCT angiography. AJR Am J Roentgenol. 2015;205:866872.