Airway difficulties associated with severe epistaxis.

Abstract

We wish to report an unusual cause of airway obstruction encountered during emergency surgery to control life-threatening epistaxis. An 81-year-old man with recurrent severe epistaxis was brought to the operating theatre as an emergency for examination under anaesthesia, submucous resection and nasal packing. He had been admitted one week previously with epistaxis. The bleeding at that time settled with conservative treatment and nasal packing, but his ECG showed a new left bundle branch block pattern and the serum creatinine kinase showed an increase to a peak of 1100 iu.ml−1. In view of the haemorrhage, he was not thrombolysed, but after the bleeding had settled was started on oral aspirin therapy. He suffered no complications from his presumed myocardial infarction and was discharged with a plan for medical follow up as an outpatient On emergency readmission, there was an active brisk bleed from the right nostril. Though this settled initially with packing, he continued to bleed and examination under anaesthesia was therefore advised, albeit with concern in view of his recent myocardial infarction. Anaesthesia was induced with fentanyl and thiopentone with a rapid sequence induction technique. The induction of anaesthesia was uncomplicated, and the patient's trachea was intubated with a size 9 cuffed orotracheal tube. Surgical examination of the nose revealed a brisk bleeding point in the right nostril, and a submucous resection was performed to allow access to the right nasal fossa. The right side of the nose was packed with BIPP paste above a Foley catheter inserted into the nostril. The Foley catheter was pulled back against resistance to ‘tamponade’ the nasal space, and tension maintained with a gate clamp (Fig. 1, overleaf). Haemostasis was thus secured, and the patient's trachea was extubated. On removing the tracheal tube, however, the patient suffered immediate and complete upper airway obstruction, which was resistant to simple methods to attempt to re-establish a clear airway. It was therefore decided to re-intubate the trachea, and anaesthesia was re-induced. On direct laryngoscopy, the (inflated) Foley catheter that had been inserted via the nostril could be seen passing through the vocal cords, causing complete obstruction of the airway. On deflation of the balloon and withdrawal of the catheter to a site above the cords, the obstruction wholly resolved. The patient proceeded to make an uncomplicated recovery. Insertion of a Foley catheter via the nostril to allow tamponade of the nasal space is a common technique used to control severe epistaxis resistant to simple packing alone [1]. Although no harm came to the patient in this instance, the case serves to reiterate the need to check the airway under direct vision if there is any doubt as to the cause of airway obstruction. Blind nasal intubation is not the sole preserve of the anaesthetist!