Anaesthetic trauma

Dental damage

Dental damage most often occurs during direct laryngoscopy, the upper incisors are most frequently damaged and diseased or restored teeth are most at risk. Avulsed teeth should be stored in milk or saline (never water) for possible re-implantation by dental surgeons. Dental damage is the most common cause of a civil action against anaesthetists, and a careful assessment of pre-anaesthetic dental condition may prevent subsequent claims.

Naso/pharyngeal/oesophageal damage

Damage to the nasal turbinates, even complete avulsion, or perforation of the nasopharyngeal mucosa can occur during nasal intubation. Intubation over a guide, such as a suction catheter or endoscope is recommended. Se psis following pharyngeal or oesophageal perforation during intubation is one of the principal causes of anaesthetic mortality. Urgent treatment is required (antibiotics and drainage) and patients in whom perforation is suspected should be closely observed for symptoms (sore throat, cervical or chest pain, dysphagia) and signs (fever).

Glottic damage

A persistent sore throat, weak cough and dysphonia should prompt a laryngoscopy. Possible causes include subluxation of an arytenoid cartilage (Figure 22.2), vocal cord palsy or haematoma (Figure 22.3). The diagnosis of arytenoid subluxation has followed intubations that were regarded as easy by the anaesthetist, but Paulsen et al failed to induce arytenoid subluxation in cadaver specimens despite strenuous efforts. They proposed that trauma at intubation causes ‘cricoarytenoid joint dysfunction’.

Tracheal damage

Acute

Perforation or rupture can occur during intubation and is not always obvious immediately. The cardinal sign is subcutaneous air. A tracheal tube may need to be placed below a rupture. The use of fibreoptic placement of two microlaryngoscopy tubes has been reported.