Palatal perforation associated with McGrath® videolaryngoscope

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A healthy patient presented for elective nasendoscopy and possible laser palatoplasty. The patient was sedated with target controlled propofol infusion guided by cerebral monitoring (BIS; Aspect Medical, Norwood, MA, USA). Glycopyrrolate and dexamethasone were given. Nasendoscopy demonstrated a floppy soft palate with incidental lingual tonsil hypertrophy. A decision was made to proceed to palatal reduction. Balanced anaesthesia was provided with target controlled propofol infusion and remifentanil and neuromuscular relaxation with a bolus of rocuronium. Facemask ventilation was easy.

Direct laryngoscopy with a Macintosh 3 blade revealed a Cormack and Lehane grade 3a view. A McGrath (Series 5) videolaryngoscope (Aircraft Medical Limited, Edinburgh, UK). easily allowed visualisation of the laryngeal inlet. A lubricated 14 F malleable stylet (Mallinkrodt Satin Slip, Tyco, Pleasanton, CA, USA) was inserted into an 8.5 Internal Diameter RAE tracheal tube (Portex, Hyde, Kent) and shaped to produce a 90°‘hockey stick’ configuration. The tip of the stylet did not protrude beyond the tracheal tube. The tube-stylet assembly was advanced into the mouth but the tip was not seen on the McGrath screen and on removal blood was seen on the tube. Direct inspection showed a palatal perforation on the right side of the soft palate. Tracheal intubation was then achieved without further incident with the aid of an introducer (Frova; Cook Medical, Bloomington, IN, USA). The perforation was repaired, the intended surgery completed and the patient made a full recovery.

The McGrath videolaryngoscope has been used for elective and emergency airway management without complication [1]. Before this case, the intubator had used the McGrath on over 100 occasions without incident. Videolayngoscopes such as the McGrath® and the GlideScope® (Verathon Medical, Bothell, WA, USA) often provide a superior view of the laryngeal inlet compared to conventional direct laryngoscopy. However the tracheal tube, once inserted into the mouth, passes the oral cavity through a ‘blind spot’ until it is seen on the screen of the videolaryngoscope. Within this ‘blind spot’, trauma is possible.

Trauma may be worsened by tube shape and rigidity conferred by the stylet. Whilst stylet use has been described as mandatory [1], others have used a tracheal tube with a steerable tip, the Endoflex® (Merlyn Associates, Tustin, CA, USA) [2] and others a flexible fibreoptic bronchoscope as a controllable tube introducer [3].

This complication has been reported following use of the GlideScope® [4–6]. We believe that this is the first report of such airway trauma associated with the McGrath® videolaryngoscope.

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