Epiglottic prolapse induced by lighted stylet tracheal intubation

Abstract

We report a case of epiglottic prolapse induced by lighted stylet tracheal intubation perceived by following upper gastrointestinal endoscopy. A 68-year-old male was to undergo endoscopic mucosal resection (EMR) under general anesthesia for a superficial orolarynx cancer spreading over the root of the tongue. Because the mucosal change was so minimal, intubation was performed with a lighted stylet instead of a direct laryngoscope, to prevent its metal blade spoiling the delicate endoscopic findings. After intubation, endoscopy revealed that the epiglottis folded down completely into the laryngeal vestibule. Immediate extubation with a ventilating tube exchanger failed to turn the entrapped epiglottis back to normal, and the inlet of the larynx remained obstructed. After reintubation, the epiglottis was restored to its normal position with endoscopic forceps. The postoperative course was uneventful and he was discharged on the sixth postoperative day. Retrospective evaluation of preoperative gastrointestinal endoscopy showed the epiglottis was flat and thin enough to have a tendency to become attached to the posterior pharynx wall, even though the procedure was performed in the decubitus position. Epiglottic prolapse induced by lighted stylet tracheal intubation is a quite rare complication but we should be aware of it as a potential injury which could cause upper airway obstruction if not recognized before extubation.

Paradoxical movements of the epiglottis: A rare cause of respiratory obstruction and its surgical treatment

“…The hanging epiglottis may be the reason for urgent intubation or tracheostomy [1]. The flat and thin epiglottis may cause complications during intubation by interfering with the vestibule of the larynx [4].…”

Atraumatic intubation: Experience using a 5.0 endotracheal tube without a Stylet for laryngeal surgery

“…For any procedure, but specifically laryngeal surgery, intubation injury can be problematic for the surgeon and patient. Personal experience as well as reports in the literature prompted this study to determine the ease of intubation using a 5.0 ETT without a stylet . The assumption utilized in clinical practice, that the small, flexible ETT requires a stylet, is without confirmatory evidence.…”

“…Personal experience as well as reports in the literature prompted this study to determine the ease of intubation using a 5.0 ETT without a stylet. 4,5 The assumption utilized in clinical practice, that the small, flexible ETT requires a stylet, is without confirmatory evidence. We found that most participants in our study could be intubated using a 5.0 ETT without a stylet, and none of these participants had laryngeal injuries.…”

“…The rigidity of the ETT with the stylet is more likely to injure delicate laryngeal tissue, and a stylet accidently protruding through the tip of the ETT can cause further damage. For example, there are reports in the literature of a prolapsed epiglottis and tracheal laceration, in addition to the more commonly seen injuries in practice …”

“…For example, there are reports in the literature of a prolapsed epiglottis and tracheal laceration, in addition to the more commonly seen injuries in practice. 4,5 Intubations with 5.0 ETT with and without a stylet are both standard practices in phonosurgery. Given the additional risks, intubation without the stylet is preferred in our practice.…”