Postoperative Uvular Edema in a Child After General Anesthesia via a Laryngeal Mask Airway Jia Huang, MD and Inca Chui, MD We describe a case of postoperative uvular edema in a pediatric patient who underwent general anesthesia via a laryngeal mask airway at our institution. Although numerous cases of uvular trauma have been reported in the literature, its association with laryngeal mask airway use remains rare. (A&A Case Reports. 2014;2:37–8.)
S
ince its development by Dr. Archie Brain in 1981 and its approval by the Food and Drug Administration in 1991, the laryngeal mask airway (LMA) has become a popular tool of airway management in both adults and children.1 The advantages of an LMA include speed of insertion, better hemodynamic stability during insertion and removal, as well as less airway stimulation. However, its use is not without complications, which include trauma to the oropharynx and possible risks of regurgitation and aspiration of gastric contents. We describe a case of uvular trauma associated with LMA use in a pediatric patient. Parental consent was not obtained because our patient was lost to follow-up. We consulted our IRB, which determined that written approval was not necessary for publication of this report.
CASE DESCRIPTION
An otherwise healthy 6-year-old boy presented to our institution for excisional biopsy of a right facial subcutaneous mass under general anesthesia. After premedication with 12 mg midazolam syrup 20 minutes before the procedure, and inhaled induction of anesthesia with sevoflurane, nitrous oxide, and oxygen, an IV catheter was inserted, and a partially deflated and well-lubricated size 2.5 LMAa was inserted atraumatically and successfully on the first attempt. The LMA was noted to have a good seal after inflation with an air leak at about 25 cm H2O. After the hour-long procedure, the LMA was removed while the patient was spontaneously breathing but still deeply anesthetized. He was then transported to the recovery area where he was closely monitored for airway patency and hemodynamic stability. In the recovery area, he complained of a sore throat but was able to tolerate liquids by mouth. At home, 3 hours after discharge, he experienced dysphagia, odynophagia, as well as a foreign body sensation in his throat. His mother noted swelling in the back of his throat and brought him back to the hospital. Physical examination by a consulting otolaryngologist revealed an erythematous and edematous uvula
From the Department of Anesthesiology, NYU Medical Center, New York, New York. Accepted for publication August 12, 2013. Funding: None. The authors declare no conflicts of interest. Address correspondence to Jia Huang, MD, Department of Anesthesiology, NYU Medical Center, 550 First Ave., New York, NY 10016. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1097/ACC.0b013e3182a995ef
February 15, 2014 • Volume 2 • Number 4
(Fig. 1). In the emergency ward, the child received 1 dose of solumedrol 50 mg IV. Although he maintained spontaneous room air breathing without signs of respiratory distress, he was transferred to the pediatric intensive care unit for airway precautions and was treated with IV decadron 10 mg every 6 hours. His symptoms improved overnight, and he was discharged home the next day to receive a 3-day course of oral prednisone. At follow-up 1 week after discharge, the patient’s father reported improvement of his son’s symptoms, including decreased dysphagia and phagophobia.
DISCUSSION
Uvular swelling caused by mechanical trauma has been described after tracheal intubation2,3 without or with nasalb and oral airway use,c upper gastrointestinal endoscopy,4 and aggressive oral suctioning.5,6 Uvular trauma caused by LMA insertion, however, has been rarely reported.d7 Emmett et al.7 described a 32-year-old woman who presented with uvular necrosis 4 days after general anesthesia with an LMA for a minor gynecological procedure. Lee also reported a “bruised
Figure 1. Physical examination revealed an erythematous and edematous uvula in a 6-year-old boy who underwent excision of a subcutaneous cheek lesion. LMA™ Unique, single-use, manufactured by The Laryngeal Mask Company Limited, Le Rocher, Victoria, Mahe, Seychelles
a
Seigne TD, Felske A, delguidice PA. Uvular edema [letter]. Anesthesiology 1978;2:37–38
b
c Shulman MS. Uvular edema without endotracheal intubation [letter]. Anesthesiology. 1981;55:82–3 d Lee JJ. Laryngeal mask and trauma to uvula [letter]. Anaesthesia. 1989;44:1014
cases-anesthesia-analgesia.org
37
Uvular Trauma in a Pediatric Patient After LMA Use
uvula” in a patient of unknown age after LMA use for a minor peripheral vascular procedure.d The mechanism of uvular trauma in both cases, as well as that in our patient, is unclear. In our case, the actual LMA insertion and removal were atraumatic, and the LMA was not overinflated after placement. Emmett et al.7 speculate that using an LMA for a prolonged procedure may be complicated by increased cuff pressure due to the diffusion of nitrous oxide and carbon dioxide into the cuff. Our case lasted for 1 hour, and nitrous oxide was discontinued after induction of anesthesia. These authors also hypothesized that men are at increased risk of uvular trauma likely due to increased soft tissues in their oropharynx.7 Many pediatric patients often have tonsillar hypertrophy, which may also complicate LMA placement. The treatment of postoperative uvular edema described in case reports varies but mainly consists of supportive measures including nebulized racemic epinephrine,8 humidified air,2,8 IV diphenhydramine,c3 and IV steroid.c2,3,8 It is however unclear how effective these therapies are. Haselby and McNiece8 reported a case of complete airway obstruction secondary to uvular edema associated with the sitting position in a 20-month-old infant after general endotracheal anesthesia that did not resolve immediately with nebulized racemic epinephrine and IV dexamthasone.
38 cases-anesthesia-analgesia.org
Therefore, it may be appropriate to monitor patients with uvular injury and potential respiratory distress in an intensive care setting. In conclusion, postoperative uvular edema is a rare complication after airway instrumentation. Its effects in pediatric patients can be profound, and it is important to assess symptoms carefully in the postoperative pediatric patient to exclude possible uvular swelling and airway obstruction. REFERENCES 1 Pennant JH, White PF. The laryngeal mask airway. Anesthesiology 1993;79:144–63 2. Diaz JH. Is uvular edema a complication of endotracheal intubation? Anesth Analg 1993;76:1139–41 3. Ravindran R, Priddy S. Uvular edema, a rare complication of endotracheal intubation. Anesthesiology 1978;48:374 4. Peghini PL, Salcedo JA, Al-Kawas FH. Traumatic uvulitis: a rare complication of upper GI endoscopy. Gastrointest Endosc 2001;53:818–20 5. Bogetz MS, Tupper BJ, Vigil AC. Too much of a good thing: uvular trauma caused by overzealous suctioning. Anesth Analg 1991;72:125–6 6. Gilmore T, Mirin M. Traumatic uvulitis from a suction catheter. J Emerg Med 2012;43:e479–80 7. Emmett SR, Lloyd SD, Johnston MN. Uvular trauma from a laryngeal mask. Br J Anaesth 2012;109:468–9 8. Haselby KA, McNiece WL. Respiratory obstruction from u vular edema in a pediatric patient. Anesth Analg 1983;62:1127–8
A & A case reports
S
ince its development by Dr. Archie Brain in 1981 and its approval by the Food and Drug Administration in 1991, the laryngeal mask airway (LMA) has become a popular tool of airway management in both adults and children.1 The advantages of an LMA include speed of insertion, better hemodynamic stability during insertion and removal, as well as less airway stimulation. However, its use is not without complications, which include trauma to the oropharynx and possible risks of regurgitation and aspiration of gastric contents. We describe a case of uvular trauma associated with LMA use in a pediatric patient. Parental consent was not obtained because our patient was lost to follow-up. We consulted our IRB, which determined that written approval was not necessary for publication of this report.
CASE DESCRIPTION
An otherwise healthy 6-year-old boy presented to our institution for excisional biopsy of a right facial subcutaneous mass under general anesthesia. After premedication with 12 mg midazolam syrup 20 minutes before the procedure, and inhaled induction of anesthesia with sevoflurane, nitrous oxide, and oxygen, an IV catheter was inserted, and a partially deflated and well-lubricated size 2.5 LMAa was inserted atraumatically and successfully on the first attempt. The LMA was noted to have a good seal after inflation with an air leak at about 25 cm H2O. After the hour-long procedure, the LMA was removed while the patient was spontaneously breathing but still deeply anesthetized. He was then transported to the recovery area where he was closely monitored for airway patency and hemodynamic stability. In the recovery area, he complained of a sore throat but was able to tolerate liquids by mouth. At home, 3 hours after discharge, he experienced dysphagia, odynophagia, as well as a foreign body sensation in his throat. His mother noted swelling in the back of his throat and brought him back to the hospital. Physical examination by a consulting otolaryngologist revealed an erythematous and edematous uvula
From the Department of Anesthesiology, NYU Medical Center, New York, New York. Accepted for publication August 12, 2013. Funding: None. The authors declare no conflicts of interest. Address correspondence to Jia Huang, MD, Department of Anesthesiology, NYU Medical Center, 550 First Ave., New York, NY 10016. Address e-mail to [email protected]. Copyright © 2014 International Anesthesia Research Society DOI: 10.1097/ACC.0b013e3182a995ef
February 15, 2014 • Volume 2 • Number 4
(Fig. 1). In the emergency ward, the child received 1 dose of solumedrol 50 mg IV. Although he maintained spontaneous room air breathing without signs of respiratory distress, he was transferred to the pediatric intensive care unit for airway precautions and was treated with IV decadron 10 mg every 6 hours. His symptoms improved overnight, and he was discharged home the next day to receive a 3-day course of oral prednisone. At follow-up 1 week after discharge, the patient’s father reported improvement of his son’s symptoms, including decreased dysphagia and phagophobia.
DISCUSSION
Uvular swelling caused by mechanical trauma has been described after tracheal intubation2,3 without or with nasalb and oral airway use,c upper gastrointestinal endoscopy,4 and aggressive oral suctioning.5,6 Uvular trauma caused by LMA insertion, however, has been rarely reported.d7 Emmett et al.7 described a 32-year-old woman who presented with uvular necrosis 4 days after general anesthesia with an LMA for a minor gynecological procedure. Lee also reported a “bruised
Figure 1. Physical examination revealed an erythematous and edematous uvula in a 6-year-old boy who underwent excision of a subcutaneous cheek lesion. LMA™ Unique, single-use, manufactured by The Laryngeal Mask Company Limited, Le Rocher, Victoria, Mahe, Seychelles
a
Seigne TD, Felske A, delguidice PA. Uvular edema [letter]. Anesthesiology 1978;2:37–38
b
c Shulman MS. Uvular edema without endotracheal intubation [letter]. Anesthesiology. 1981;55:82–3 d Lee JJ. Laryngeal mask and trauma to uvula [letter]. Anaesthesia. 1989;44:1014
cases-anesthesia-analgesia.org
37
Uvular Trauma in a Pediatric Patient After LMA Use
uvula” in a patient of unknown age after LMA use for a minor peripheral vascular procedure.d The mechanism of uvular trauma in both cases, as well as that in our patient, is unclear. In our case, the actual LMA insertion and removal were atraumatic, and the LMA was not overinflated after placement. Emmett et al.7 speculate that using an LMA for a prolonged procedure may be complicated by increased cuff pressure due to the diffusion of nitrous oxide and carbon dioxide into the cuff. Our case lasted for 1 hour, and nitrous oxide was discontinued after induction of anesthesia. These authors also hypothesized that men are at increased risk of uvular trauma likely due to increased soft tissues in their oropharynx.7 Many pediatric patients often have tonsillar hypertrophy, which may also complicate LMA placement. The treatment of postoperative uvular edema described in case reports varies but mainly consists of supportive measures including nebulized racemic epinephrine,8 humidified air,2,8 IV diphenhydramine,c3 and IV steroid.c2,3,8 It is however unclear how effective these therapies are. Haselby and McNiece8 reported a case of complete airway obstruction secondary to uvular edema associated with the sitting position in a 20-month-old infant after general endotracheal anesthesia that did not resolve immediately with nebulized racemic epinephrine and IV dexamthasone.
38 cases-anesthesia-analgesia.org
Therefore, it may be appropriate to monitor patients with uvular injury and potential respiratory distress in an intensive care setting. In conclusion, postoperative uvular edema is a rare complication after airway instrumentation. Its effects in pediatric patients can be profound, and it is important to assess symptoms carefully in the postoperative pediatric patient to exclude possible uvular swelling and airway obstruction. REFERENCES 1 Pennant JH, White PF. The laryngeal mask airway. Anesthesiology 1993;79:144–63 2. Diaz JH. Is uvular edema a complication of endotracheal intubation? Anesth Analg 1993;76:1139–41 3. Ravindran R, Priddy S. Uvular edema, a rare complication of endotracheal intubation. Anesthesiology 1978;48:374 4. Peghini PL, Salcedo JA, Al-Kawas FH. Traumatic uvulitis: a rare complication of upper GI endoscopy. Gastrointest Endosc 2001;53:818–20 5. Bogetz MS, Tupper BJ, Vigil AC. Too much of a good thing: uvular trauma caused by overzealous suctioning. Anesth Analg 1991;72:125–6 6. Gilmore T, Mirin M. Traumatic uvulitis from a suction catheter. J Emerg Med 2012;43:e479–80 7. Emmett SR, Lloyd SD, Johnston MN. Uvular trauma from a laryngeal mask. Br J Anaesth 2012;109:468–9 8. Haselby KA, McNiece WL. Respiratory obstruction from u vular edema in a pediatric patient. Anesth Analg 1983;62:1127–8
A & A case reports
