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Table of Contents
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 84-85

Accidental endotracheal tube migration following diffusion of nitrous oxide in mastoid surgery

1 Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Anaesthesiology and Critical Care Medicine, All India Institute of Medical Sciences, Patna, Bihar, India

Date of Submission10-Feb-2020
Date of Decision17-Feb-2020
Date of Acceptance20-Feb-2020
Date of Web Publication11-May-2020

Correspondence Address:
Dr. Neeraj Kumar
Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_9_20

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How to cite this article:
Kumar N, Kumar A, Vishwas K. Accidental endotracheal tube migration following diffusion of nitrous oxide in mastoid surgery. Bali J Anaesthesiol 2020;4:84-5

How to cite this URL:
Kumar N, Kumar A, Vishwas K. Accidental endotracheal tube migration following diffusion of nitrous oxide in mastoid surgery. Bali J Anaesthesiol [serial online] 2020 [cited 2023 Mar 23];4:84-5. Available from: https://www.bjoaonline.com/text.asp?2020/4/2/84/284186


Displacement of an endotracheal tube (ETT) can result in serious complications such as cuff rupture, damage and kinking of ETT, and accidental extubation or endobronchial intubation which ultimately can compromise the airway.[1] Early recognition and repositioning of the ETT are essential.

We report a very interesting observation of outward migration of ETT in an ASA Grade II and 35-year-old male and 70 kg bodyweight posted for left retromastoid exploration with facial nerve decompression under general anesthesia. Intraoperative facial nerve monitoring was planned for this surgery to preserve the facial nerve. After a proper preanesthetic assessment, he was posted for general anesthesia.

Anesthesia was induced as per the standard institutional protocol. The patient was intubated with 8.0-mm flexometallic tube, and the cuff was inflated by keeping initial pressure of 18 cm H20 using a pressure measuring device. Initially, the tube was fixed at 23 cm at the right angle of the mouth using an adhesive bandage. The placement was confirmed by bilateral chest auscultation. Anesthesia was maintained with isoflurane 0.75% with oxygen and nitrous oxide mixture. Infusion of dexmedetomidine at a rate of 0.7 μg/kg/h was started for facial nerve monitoring (as no muscle relaxant was used).

Intraoperative continuous facial nerve monitoring using electromyography was started by placing two subdermal monopolar paired needle at the upper eyelid (musculus orbicularis oculi), and other to the corner of the left side of the mouth (musculus orbicularis oris), respectively. We tried to keep intraoperative Bispectral index score (BIS) value between 40 and 50.

One hour after the surgery, we heard ventilatory alarm showing a sudden rise in peak airway pressure to 29 cm H20 from 13 cm H20. We quickly assess for any kinking of the tube or circuit and we saw that pilot balloon pressure of ETT was much inflated leading to outside migration of the ETT [Figure 1]. ETT cuff pressure measurement showed 23 cm H20 pressure. We released the pilot balloon pressure, and again repositioned and fixed the ET Tube at 23 cm on the right angle of mouth.
Figure 1: Arrow showing outward migration of flexometallic tube

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There are various reasons for accidental extubation and some of these are inappropriate relaxation together with a light plane of anesthesia, loose cloth tape fixation, movement of patient's head during surgical exploration, accidental traction of ETT by the surgeon's hand, and inappropriate tube fixation.[2] We know these modern tracheal tube cuffs are usually made of polyvinyl chloride, which is permeable to N2O. Diffusion of N2O into a cuff is dependent on the permeability coefficient of the cuff wall and is inversely proportional to the thickness of the cuff wall.[3]

An increase in cuff volume and intracuff pressure of an ETT due to nitrous oxide diffusion is well documented.[4] With the use of nitrous oxide at a concentration >50%, it may diffuse into the cuff of the ETT, which further increases the cuff pressure and may lead to ETT migration.[5] In our institution, we used nitrous oxide and isoflurane to maintain minimum alveolar concentration. Hence, we always have to pay extra attention to cuff pressure monitoring during anesthesia if nitrous oxide is being used. This ET migration was probably happened due to diffusion of nitrous oxide and fixation of adhesive tape at one side of the mouth due to the placement of subdermal implants that may aid in outward migration.

During surgeries such as mastoid or parotid, if facial nerve monitoring is being planned cautiously use nitrous oxide and always give attention for ETT fixation using bandage in addition to adhesive tapes and a water-resistant medical dressing. This not only prevents loosening of the adhesive tapes because of the drooling of saliva, especially in mastoid or parotid surgeries but also prevents ETT migration.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Nishikawa K, Nagashima C, Shimodate Y, Igarashi M, Namiki A. Migration of the endotracheal tube during laparoscopy-assisted abdominal surgery in young and elderly patients. Can J Anaesth 2004;51:1053-4.  Back to cited text no. 1
Ali QE, Amir SH, Kamal S, Bansal S. Management of accidental extubation during oral surgery by nasotracheal intubation using the King vision video laryngoscope and a gum elastic bougie – A case report. Rom J Anaesth Intensive Care 2015;22:133-5.  Back to cited text no. 2
Chandler M. Pressure changes in tracheal tube cuffs. Anaesthesia 1986;41:287-93.  Back to cited text no. 3
Stanley TH, Kawamura R, Graves C. Effects of nitrous oxide on volume and pressure of endotracheal tube cuffs. Anesthesiology 1974;41:256-62.  Back to cited text no. 4
Karasawa F, Ohshima T, Takamatsu I, Ehata T, Fukuda I, Uchihashi Y, et al. The effect on intracuff pressure of various nitrous oxide concentrations used for inflating an endotracheal tube cuff. Anesth Analg 2000;91:708-13.  Back to cited text no. 5


  [Figure 1]


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