A Case of Nasal Mucosa Cautery With Reintubation Under Pharyngeal Suction for Massive Epistaxis After Extubation

CASE REPORT

A 27-year-old woman (height 156 cm, weight 47 kg, body mass index 19.3 kg/m²) was scheduled for maxillary Le Fort I osteotomy and mandibular bilateral sagittal split osteotomies to correct maxillofacial deformities. She had a history of atopic dermatitis, allergic rhinitis, and retinal detachment; reported allergies to latex, walnuts, and ampicillin; and was taking bilastine daily. The patient denied any history of epistaxis, and preoperative nasal endoscopy showed no abnormal nasal cavity morphology or cysts. No abnormal findings were noted during her routine preoperative examination.

After induction of general anesthesia, a 6.5 nasotracheal tube softened in hot water was inserted into the left nares, but difficulty was encountered as the tube seemingly became encumbered by the posterior pharyngeal wall. However, after rotating the tube, it was advanced farther without difficulty. Although minor epistaxis was noted during direct laryngoscopy, a grade II view was obtained, and nasotracheal intubation was easily accomplished. Her intraoperative vital signs were stable, and surgery was completed with only 100-mL blood loss.

During the awake extubation, the patient coughed, and blood clots were expelled from both nostrils with active bleeding detected from the nasal cavity and within the posterior oropharynx. The surgeon inserted gauze soaked in 0.1% epinephrine into both nasal cavities but failed to achieve hemostasis. When a mirror was inserted into the pharynx to locate the bleeding sites, the patient vomited from the stimulation, which resulted in increased bleeding. Thus, the decision was made to emergently reintubate the patient. Mask ventilation was not possible because of the gauze inserted in both nasal cavities and the suction catheter constantly evacuating the oral cavity, which also effectively prevented the use of supplemental oxygen. Instead of inhalational anesthetics and muscle relaxants, midazolam 5 mg and remifentanil 100 μg were administered. Another grade II view was obtained under direct laryngoscopy with continuous suctioning to control bleeding, and ∼40 seconds later, the patient was successfully reintubated with a 6.5 orotracheal tube. Her oxygen saturation (SpO₂) temporarily decreased to 68% but immediately returned to 100% with manual ventilation after the airway was secured.

The patient remained sedated and spontaneously ventilating with an infusion of dexmedetomidine 0.4 to 0.6 μg/kg/h and an additional bolus of midazolam 5 mg. After the patient's head was elevated, an otolaryngologist carefully repacked the nasal cavities with gauze, and hemostasis was eventually achieved. A rigid scope examination confirmed mucosal damage near the left sphenopalatine foramen. The dexmedetomidine infusion was continued during nasal cautery, and sevoflurane 0.5–1% was administered with the patient spontaneously ventilating. Her vital signs showed no marked changes. The patient was subsequently awakened from anesthesia with her head elevated. No agitation was observed during emergence, and she was extubated (total blood loss volume 1215 mL).

An alginate wound dressing was placed in the cauterized area, and an absorbent surgical sponge was placed behind the left side of the nasal passage. After 3 days, the surgical sponge was removed, and the alginate wound dressing underwent spontaneous shedding. The patient was discharged after 7 days and underwent flexible endoscopy 15 days later that revealed a blood clot in the posterior part of the middle meatus (Figure).

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DISCUSSION

The lateral wall of the nasal cavity near the posterior aspect of the middle meatus is a common site for injury that can lead to massive epistaxis.¹ This patient's nasal mucosa near the sphenopalatine foramen was likely damaged during nasotracheal intubation when the tube was guided into the middle meatus, where it compressed the mucosa and caused ischemia. During extubation, the wrinkles on the cuff further damaged the mucosa,² causing massive hemorrhage.

Airway management during anesthesia is often difficult in patients with massive epistaxis.³ Although the balloon from a Foley catheter can be placed in the nasal cavity and inflated to control bleeding, its presence can make it difficult to obtain a proper mask fit. Also, artificial closure of the nasal airway further impedes mask ventilation. Persistent bleeding obscures views during laryngoscopy and increases the likelihood of aspiration. In a previous report, successful awake fiber-optic intubation took 50 minutes in a patient with massive hemorrhage.⁴ Presently, we selected induction drugs according to the emergent circumstances and promptly intubated the patient. There was not sufficient time to consider performing an awake intubation. These actions likely allowed us to secure the airway and prevent pulmonary aspiration of blood.

Use of video laryngoscopy could also be considered in the event direct laryngoscopy becomes difficult. If intubation is not possible, insertion of a supraglottic airway device (ie, a laryngeal mask airway) should be considered. Control of the posterior nasal bleeding could have been attempted with a Foley catheter balloon as well. Furthermore, the continuous infusion of dexmedetomidine and maintaining spontaneous ventilation might have contributed to the suppression of circulatory fluctuation during reintubation, reduced the need for additional anesthetics, and prevented agitation during emergence.⁵

CONCLUSION

In the case of massive bleeding occurring in the upper airway after surgery, it is necessary to control bleeding and provide ample suctioning while preparing to rapidly resecure the airway. Loss of the airway must be prevented, and considerations should be given to emergent reintubation or placement of an LMA. Rapid recognition of an airway emergency, sufficient hemorrhage control, and utilization of immediately available drugs facilitated emergent reintubation and prevented pulmonary aspiration.