600
ANESTHESIA AND ANALGESI . . . Current Researches Vor.. 55. No. 4. ~LJI.Y-ALIGUST, 1976
Xeroradiography of the larynx and trachea showed subglottic stenosis and a laryngeal web (fig 2 ) . The patient underwent tracheostomy followed by repeated tracheal dilations.
PROSPECTIVE STUDY To determine the incidence of laryngotracheal abnormalities as revealed by xeroradiography, we studied 16 pediatric patients (4to 14 years) scheduled for elective open-heart operations. All were endotracheally intubated with polyvinyl-chloride tubes whose size (French) was determined by the formula “age + 17,” modified as indicated by clinical judgment. I n only 1 patient was a cuffed tube used. Fourteen of the patients were intubated for 28 hours, one for 8 hours, and one for 72 hours. Of the 16 patients, 14 showed no laryngeal or tracheal changes on xeroradiography at 24 to 72 hours after extubation. Narrowing of the trachea by 1 mm was seen in 2 patients after intubation (uncuffed) for 28 and 72 hours, respectively.
DISCUSSION While only minimal changes were observed by xeroradiography in 2/14 patients studied, more prolonged intubation, use of
low-volume, high-pressure cuffs, or xeroradiography several days after extubation might have shown different results. Indeed, the 1 patient who developed a laryngeal web after 7 days of intubation did not manifest symptoms until several days postextubation. Perhaps xeroradiography during the asymptomatic period would have revealed this lesion to be forming. The boy examined by xeroradiography before intubation, who then showed tracheal compression, was asymptomatic.
ACKNOWLEDGMENT The authors thank Dr. Eugene Klatte, Professor and Chairman, and Dr. Huen Yune, Department of Radiology, for their help, and Miss Linda Hicks for secretarial assistance. The authors thank Dr. Robert K. Stoelting for his helpful suggestions. REFERENCES 1. Symchych PS. Cadotte MD: Squamous metaplasia and necrosis of the trachea complicating prolonged nasotracheal intubation of small newborn
infants. J Pediatr 71:534-541, 1967 2. Holinger PH, Lutterbeck EF. Bulger R: Xeroradiography of the larynx. Ann Otol 81:806808, 1972
3. Doust BD, Ting YM: Xeroradiography of larynx. Radiology 110:727-730. 1974
Pneumatocele of the Larynx: A Complication of Percuta neous Tra nstrac hea I Venti Iatio n EDWARD CARDEN, M A , MB, BChir, FRCP(C)* THOMAS C. CALCATERRA, M D t ALLEN LECHTMAN, MDS Los Angeles, California5
REPORT OF A CASE suffered neck trauma in an automobile accident, requiring emergency tracheostomy through
A
~ ~ - Y E A R - O L DHawaiian
the 2nd and 3rd tracheal rings. His larynx was explored, and extensive damage to the right thyroid lamina and right vocal cord was repaired by mucosal approximation and
*Associate Professor, Department of Anesthesiology; &-Chief, Anesthesiology Section, Veterans Administration, Wadsworth. ?Associate Professor, Department of Surgery/Head and Neck. $Associate Physician, Department of Anesthesiology. %Universityof California at Los Angeles, School of Medicine, Los Angeles, California 90024. Paper received: 12/15/75 Accepted for publication: 2/25/76
Brief Reports .
601
..
a laryngeal stent, removed 3 weeks after repair. Because of glottic insufficiency, Teflon was injected into the right vocal cord area without appreciable augmentation of the posterior third of the cord. The cord was therefore nonmobile and laterally displaced, especially posteriorly. Since he had difficulty talking and coughing, he was scheduled for removal of a Teflon granuloma of the anterior aspect of the cord and Teflon injection to its posterior part. The patient received 100 mg of meperidine and 0.5 mg of atropine IM, 1 hour before operation. On his arrival in the operating room, a 16-gauge IV cannula was placed in the left arm and infusion was started. When the blood pressure cuff and ECG leads had been attached, the patient was preoxygenated for 4 minutes with loo%, 0 2 ,using a circle system with an inflow rate of 16 L/min. He was given IV fentanyl (0.2 mg) until drowsy; then, thiopental (375 mg) , and 80 mg of succinylcholine IV. A 0.2% solution of succinylcholine was infused at about 10 mgms/min. A 14-gauge, 3.8 cm Deseret Radio Opaque Teflon catheter was then inserted through the cricothyroid membrane into the trachea. (This catheter has side holes near the tip, designed originally for venous lines in patients on dialysis.) A 10-ml syringe was attached and air aspirated from the trachea to confirm position. The catheter was connected to a high-pressure jetting system consisting of a Bird high-flow N,O-0, blender, pressurereducing valve, and a flow-interrupting device.l Anesthesia was maintained by intermittent jetting from this catheter with a mixture of N,O-O.) (60:40) a t a pressure of 30 psi, producing adequate chest expansion with a n estimated tidal volume of 800 ml. As the patient had a relatively short neck, the surgeon extended the patient's head to insert the laryngoscope; in the process, the tip of the cannula was pulled back from its position in the trachea to a position between the cricothyroid membrane and the skin, with resultant expansion of the neck during jetting. Jetting was immediately stopped, while the needle was removed and replaced through the same puncture site with a 5-cm, 14-gauge needle of the same type, and the jetting system was then reattached. Ventilation of the patient was now easily maintained but the neck was still slightly swollen and the characteristic crepitus of subcutaneous emphysema could be felt. On insertion of an operating laryngoscope blade, the sur-
geon observed a large pneumatocele distending the right aryepiglottic space. This gas was aspirated easily with a 17-gauge needle on a laryngeal syringe. The proposed operation was then completed.
DISCUSSION This method of management during laryngeal operations has been advocated by various authors.'-s However, it is not without complications among which is pneumothorax due to excessive pressure in the lung if jetting is continued with the vocal cords closed or the upper airway obstructed.'; Air has been injected through the posterior side of the tracheal wall by inadvzrtently placing a long needle through the other side of the trachea.':' This could proceed to mediastinal emphysema and bilateral pneumothoraces. It is interesting that the gas was able to track through the fascia1 planes to the area of the vocal cords. The air may have spread cephalad because of fibrosis in the tissues below the site of needle puncture following healing of the tracheostomy. Also the needle puncture was a t the cricothyroid membrane rather than between the tracheal rings, which is the more common site.'-" The surgeon, however, was easily able to deal with the problem by letting out the air from the swollen area, enabling the patient to regain his normal anatomy. Since the pressure developed in the lungs is dependent upon the flow of gas from the needle, and the resistance to flow is inversely proportional to t h e length (HagenPoiseuille law), a short needle will deliver better ventilation than a long one. We now routinely use 5-cm needles for this technic. *Grant P: personal communication, 1971.
REFERENCES 1. Carden E, Vest HR: Further advances in anesthetic technics for microlaryngeal surgery. Anesth & Analg 53:584-587, 1974 2. Spoerel WE, Greenway RE: Techniques of ventilation. Br J Anaesth 43:932-939, 1971
3. Chakravarty K, Narayanan PS, Spoerel WE: Further studies on transtracheal ventilation: the influence of upper airway obstruction on the patterns of pressure and volume changes. Br J Anaesth 43: 733-736, 1973 4. Smith RB, Myers EN, Sherman H: Transtracheal Ventilation in Pediatric Patients. Br J Anaesth 46:313-314, 1974 5. Smith RB: Transtracheal ventilation during anesthesia. Anesth & Analg 53: 225-228, 1974 6. Fenwick DG, Baker R: Communication. Ann Otol (in press)
ANESTHESIA AND ANALGESI . . . Current Researches Vor.. 55. No. 4. ~LJI.Y-ALIGUST, 1976
Xeroradiography of the larynx and trachea showed subglottic stenosis and a laryngeal web (fig 2 ) . The patient underwent tracheostomy followed by repeated tracheal dilations.
PROSPECTIVE STUDY To determine the incidence of laryngotracheal abnormalities as revealed by xeroradiography, we studied 16 pediatric patients (4to 14 years) scheduled for elective open-heart operations. All were endotracheally intubated with polyvinyl-chloride tubes whose size (French) was determined by the formula “age + 17,” modified as indicated by clinical judgment. I n only 1 patient was a cuffed tube used. Fourteen of the patients were intubated for 28 hours, one for 8 hours, and one for 72 hours. Of the 16 patients, 14 showed no laryngeal or tracheal changes on xeroradiography at 24 to 72 hours after extubation. Narrowing of the trachea by 1 mm was seen in 2 patients after intubation (uncuffed) for 28 and 72 hours, respectively.
DISCUSSION While only minimal changes were observed by xeroradiography in 2/14 patients studied, more prolonged intubation, use of
low-volume, high-pressure cuffs, or xeroradiography several days after extubation might have shown different results. Indeed, the 1 patient who developed a laryngeal web after 7 days of intubation did not manifest symptoms until several days postextubation. Perhaps xeroradiography during the asymptomatic period would have revealed this lesion to be forming. The boy examined by xeroradiography before intubation, who then showed tracheal compression, was asymptomatic.
ACKNOWLEDGMENT The authors thank Dr. Eugene Klatte, Professor and Chairman, and Dr. Huen Yune, Department of Radiology, for their help, and Miss Linda Hicks for secretarial assistance. The authors thank Dr. Robert K. Stoelting for his helpful suggestions. REFERENCES 1. Symchych PS. Cadotte MD: Squamous metaplasia and necrosis of the trachea complicating prolonged nasotracheal intubation of small newborn
infants. J Pediatr 71:534-541, 1967 2. Holinger PH, Lutterbeck EF. Bulger R: Xeroradiography of the larynx. Ann Otol 81:806808, 1972
3. Doust BD, Ting YM: Xeroradiography of larynx. Radiology 110:727-730. 1974
Pneumatocele of the Larynx: A Complication of Percuta neous Tra nstrac hea I Venti Iatio n EDWARD CARDEN, M A , MB, BChir, FRCP(C)* THOMAS C. CALCATERRA, M D t ALLEN LECHTMAN, MDS Los Angeles, California5
REPORT OF A CASE suffered neck trauma in an automobile accident, requiring emergency tracheostomy through
A
~ ~ - Y E A R - O L DHawaiian
the 2nd and 3rd tracheal rings. His larynx was explored, and extensive damage to the right thyroid lamina and right vocal cord was repaired by mucosal approximation and
*Associate Professor, Department of Anesthesiology; &-Chief, Anesthesiology Section, Veterans Administration, Wadsworth. ?Associate Professor, Department of Surgery/Head and Neck. $Associate Physician, Department of Anesthesiology. %Universityof California at Los Angeles, School of Medicine, Los Angeles, California 90024. Paper received: 12/15/75 Accepted for publication: 2/25/76
Brief Reports .
601
..
a laryngeal stent, removed 3 weeks after repair. Because of glottic insufficiency, Teflon was injected into the right vocal cord area without appreciable augmentation of the posterior third of the cord. The cord was therefore nonmobile and laterally displaced, especially posteriorly. Since he had difficulty talking and coughing, he was scheduled for removal of a Teflon granuloma of the anterior aspect of the cord and Teflon injection to its posterior part. The patient received 100 mg of meperidine and 0.5 mg of atropine IM, 1 hour before operation. On his arrival in the operating room, a 16-gauge IV cannula was placed in the left arm and infusion was started. When the blood pressure cuff and ECG leads had been attached, the patient was preoxygenated for 4 minutes with loo%, 0 2 ,using a circle system with an inflow rate of 16 L/min. He was given IV fentanyl (0.2 mg) until drowsy; then, thiopental (375 mg) , and 80 mg of succinylcholine IV. A 0.2% solution of succinylcholine was infused at about 10 mgms/min. A 14-gauge, 3.8 cm Deseret Radio Opaque Teflon catheter was then inserted through the cricothyroid membrane into the trachea. (This catheter has side holes near the tip, designed originally for venous lines in patients on dialysis.) A 10-ml syringe was attached and air aspirated from the trachea to confirm position. The catheter was connected to a high-pressure jetting system consisting of a Bird high-flow N,O-0, blender, pressurereducing valve, and a flow-interrupting device.l Anesthesia was maintained by intermittent jetting from this catheter with a mixture of N,O-O.) (60:40) a t a pressure of 30 psi, producing adequate chest expansion with a n estimated tidal volume of 800 ml. As the patient had a relatively short neck, the surgeon extended the patient's head to insert the laryngoscope; in the process, the tip of the cannula was pulled back from its position in the trachea to a position between the cricothyroid membrane and the skin, with resultant expansion of the neck during jetting. Jetting was immediately stopped, while the needle was removed and replaced through the same puncture site with a 5-cm, 14-gauge needle of the same type, and the jetting system was then reattached. Ventilation of the patient was now easily maintained but the neck was still slightly swollen and the characteristic crepitus of subcutaneous emphysema could be felt. On insertion of an operating laryngoscope blade, the sur-
geon observed a large pneumatocele distending the right aryepiglottic space. This gas was aspirated easily with a 17-gauge needle on a laryngeal syringe. The proposed operation was then completed.
DISCUSSION This method of management during laryngeal operations has been advocated by various authors.'-s However, it is not without complications among which is pneumothorax due to excessive pressure in the lung if jetting is continued with the vocal cords closed or the upper airway obstructed.'; Air has been injected through the posterior side of the tracheal wall by inadvzrtently placing a long needle through the other side of the trachea.':' This could proceed to mediastinal emphysema and bilateral pneumothoraces. It is interesting that the gas was able to track through the fascia1 planes to the area of the vocal cords. The air may have spread cephalad because of fibrosis in the tissues below the site of needle puncture following healing of the tracheostomy. Also the needle puncture was a t the cricothyroid membrane rather than between the tracheal rings, which is the more common site.'-" The surgeon, however, was easily able to deal with the problem by letting out the air from the swollen area, enabling the patient to regain his normal anatomy. Since the pressure developed in the lungs is dependent upon the flow of gas from the needle, and the resistance to flow is inversely proportional to t h e length (HagenPoiseuille law), a short needle will deliver better ventilation than a long one. We now routinely use 5-cm needles for this technic. *Grant P: personal communication, 1971.
REFERENCES 1. Carden E, Vest HR: Further advances in anesthetic technics for microlaryngeal surgery. Anesth & Analg 53:584-587, 1974 2. Spoerel WE, Greenway RE: Techniques of ventilation. Br J Anaesth 43:932-939, 1971
3. Chakravarty K, Narayanan PS, Spoerel WE: Further studies on transtracheal ventilation: the influence of upper airway obstruction on the patterns of pressure and volume changes. Br J Anaesth 43: 733-736, 1973 4. Smith RB, Myers EN, Sherman H: Transtracheal Ventilation in Pediatric Patients. Br J Anaesth 46:313-314, 1974 5. Smith RB: Transtracheal ventilation during anesthesia. Anesth & Analg 53: 225-228, 1974 6. Fenwick DG, Baker R: Communication. Ann Otol (in press)
