Case 22: Postoperative Airway Complication Following Sinus Surgery

Abstract

A 28-year-old man (ASA 1) with chronic sinusitis is scheduled for functional endoscopic sinus surgery (FESS) since he has failed medical management. He is 84 kg and 5 feet 10 inches. He has had one previous general anesthetic for an acute appendix at age 10. Otherwise his medical history and physical exam is unremarkable. He is at present not taking any medication and has no known allergies to medicines. He has a normal white cell count and his Hb is 14 mg%. After sedation with midazolam 2 mg IV, he is taken to the operating room where a routine general anesthetic is induced uneventfully. Tracheal intubation (grade 1 view) is done atraumatically on the first attempt after the patient is fully checked to be fully paralyzed with a nerve stimulator (vecuronium 7 mg.). The pharynx is deemed normal both preoperatively and during endotracheal intubation. The endotracheal tube (ETT) is secured, and bilateral air entry is recorded with presence of CO₂ on the capnograph. General anesthesia is maintained with oxygen, nitrous oxide, isoflurane, morphine, and fentanyl. The operation lasts 90 min, and the vital signs throughout the surgery are within normal limits. The estimated blood loss is 900 ml. No airways or oral packs are used during the surgery, except a nasal posterior pack that was placed before the FESS commenced and removed after surgery. The inferior nasal vault was not packed, but small hemostatic sponges were placed in the ethmoid cavities. Before the patient was fully awake, the pharynx was gently suctioned using Yankauer suction, an oral gastric tube placed on its first attempt, suction applied, and the tube withdrawn completely. 50 ml of gastric juice was aspirated. With the patient fully awake and able to follow commands, the ETT is removed. In the recovery room, the patient is comfortable with stable vital signs. However, 10 min later he complains of coughing and difficulty in breathing. Despite supplemental oxygen (6 l/min) via an oxygen mask, his oxygen saturation decreased to 86%. You are called back and examine the patient’s chest and can hear only minimal scattered expiratory noises (stridors). Racemic epinephrine is given with minimal improvement. You put another saturation monitor on his finger but the saturation is still 86%.