Patients who have undergone maxillectomy and complex reconstructions are at risk of developing naso- or orbito-cutaneous fistulae. This population is likely to require further operations and may become impossible to bag-valve-mask ventilate because of persistent air leak through the fistulous tract located outside the area covered by a mask. As recently described by Bhatnagar and Agarwal,1 a fistula opening can be obliterated with dry pad packing.1 We propose an alternative, less invasive, and faster technique to effectively preoxygenate, induce, and secure the airway in such cases.
The patient has provided written consent to publish this case report.
A 63-year-old American Society of Anesthesiologists III man with a history of maxillary sinus squamous cell carcinoma presented for a paramedian forehead flap to close a nasocutaneous fistula resulting from a complication of wide resection with osteocutaneous radial forearm reconstruction of the maxillary tumor. Chest radiograph, electrocardiogram, and routine laboratory values were normal. The patient had no pulmonary or metabolic issues. Physical examination was significant for body mass index: 24 kg/m2, facial deformity with entropion from suture line and wound dehiscence over the left nasal bridge (Figure 1). A small amount of plate and middle nasal vault were visible through a 1-cm cutaneous opening.
A review of the patient’s prior anesthetic records showed a Cormack-Lehane grade I view during direct laryngoscopy, at the beginning of his initial surgery. To secure the patient’s airway, our initial plan was awake fiberoptic intubation. However, the patient could not speak English and did not cooperate for even a simple airway examination. Because there was no apparent change to oral or laryngeal anatomy, we believed that as long as the patient could maintain spontaneous respiration or could be ventilated with positive pressure by mask, intubation by direct laryngoscopy should be possible and safe. Consequently, we choose an inhalational induction, preserving spontaneous respiration, until the patient was sufficiently anesthetized for laryngoscopy. Because the opening of the fistula extended outside the radius of a large adult mask and would act as a shunt between the anesthetic system and the room air, it would have to be obliterated in order to preoxygenate and ventilate effectively.
The patient was taken to the operating room for general anesthesia and standard monitors were applied. The patient was initially agitated and therefore was given midazolam 2 mg and fentanyl 25 µg intravenously (IV) to facilitate placement of an adult anesthetic mask. Preoxygenation with 100% oxygen was attempted by 2 anesthesia providers. However, the large leak from the nasocutaneous fistula reduced the blood oxygen saturation level (Spo2) to <100%, as we anticipated. At this point, a 4″ by 4 ¾″ occlusive transparent dressing was placed over the defect and closed left eye, to cover the cutaneous opening of the fistula (Figure 2). Complete occlusion was achieved and, after successful preoxygenation, a modified inhalational induction was begun with propofol 40 mg IV followed by increasing percentage of inhaled sevoflurane. Spontaneous patient respiration was maintained with the aid of an oral airway and confirmed by capnography. End-tidal CO2 was 38 mm Hg and the patient’s heart rate and blood pressure were maintained within 20% of preinduction values. Once an end-tidal sevoflurane concentration of 7.5% was achieved, video-assisted laryngoscopy was used to visualize the vocal cords and a 7.0 cuffed endotracheal tube (ETT) passed easily into the trachea. Bilateral breath sounds and the presence of end-tidal CO2 further confirmed correct placement of the ETT and vecuronium 10 mg IV was given. The ETT was secured to the lower mandible with a combination of tape and suture. The right eye was taped closed and the left eye was protected with a corneal shield after the occlusive transparent dressing was removed.
Fistula formation has been described as a consequence of resection of sinonasal malignancies,2 and several risk factors, including histologic type and surgical approach have been identified.3 Most patients require multiple major reconstructive surgeries to successfully repair these defects.4 Mask ventilation is the single most challenging consideration in providing general anesthesia in this patient population due to persistent communication between the nasal cavity and the skin between nose and eyes. As recently reported by Bhatnagar and Agarwal,1 if the fistula opening lies outside the radius of the anesthesia mask, an adequate seal will be impossible to achieve. Common predictors of difficult mask ventilation including age >55 years, body mass index >26 kg/m2, beard, lack of teeth, and a history of snoring were absent in our patient.5 However, we proceeded on the assumption that this patient could be a difficult airway case given the postsurgical changes to his face and airway. The problem of incomplete mask seal was resolved by covering the defect with a transparent adhesive dressing and applying gentle pressure with a mask, thereby, obviating the effects of the fistulous tract and thus enabling manual ventilation (Figure 3).
With this case report, we intended to create awareness about the prevalence of nasocutaneous fistula and the challenges that it represents for the anesthesia provider. We demonstrated that preoxygenation and bag mask ventilation are possible with temporary occlusion of the fistula opening, after which standard or modified airway management techniques can be used safely.
Name: Ivanna A. Sanoja, MD.
Contribution: This author helped review the literature and write the manuscript.
Name: Kenneth S. Toth, MD, PhD.
Contribution: This author helped develop the anesthetic plan, conception of the article, and provided critical revision including grammar and spelling.
This manuscript was handled by: Raymond C. Roy, MD.
1. Bhatnagar A, Agarwal ANaso-orbital fistula and socket reconstruction with radial artery forearm flap following orbital mucormycosis. Natl J Maxillofac Surg. 2016;7:197200.
2. Larsson LG, Martensson GCarcinoma of the paranasal sinuses and the nasal cavities; a clinical study of 379 cases treated at Radiumhemmet and the Otolaryngologic Department of Karolinska Sjukhuset, 1940-1950. Acta Radiol. 1954;42:149172.
3. Cianchetti M, Varvares MA, Deschler DG, Liebsch NJ, Wang JJ, Chan AWRisk of sinonasal-cutaneous fistula after treatment for advanced sinonasal cancer. J Surg Oncol. 2012;105:261265.
4. Hanasono MM, Lee JC, Yang JS, Skoracki RJ, Reece GP, Esmaeli BAn algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital exenteration. Plast Reconstr Surg. 2009;123:98105.
5. Langeron O, Masso E, Huraux CPrediction of difficult mask ventilation. Anesthesiology. 2000;92:12291236.