When an Airway Conduit becomes an Unusual Obstruction!

Dear Editor, The nasopharyngeal airway (NPA) helps maintain airway patency and facilitates nasotracheal suctioning. It plays an important role in awake nasal fibreoptic intubation, especially in patients with limited mouth opening.[1] However, dislodgement poses challenges, as seen in a case where the NPA folded into the nasopharynx, obstructing airflow and requiring retrieval in a patient with minimal mouth opening. A 58-year-old male underwent wide local excision and modified neck dissection with radial forearm free flap for carcinoma buccal mucosa, necessitating flap repair [Figure 1a and b]. With near-zero mouth opening, anticipating airway difficulties, awake fibreoptic intubation was planned. The patient received preoperative decongestion and sedation for optimal cooperation. In the operating theatre, standard monitoring commenced alongside preoxygenation. Sedation with dexmedetomidine, fentanyl and midazolam was administered.Figure 1: (a and b) A picture of the patient, a postoperative case of wide local excision and modified neck dissection with a radial forearm free flap for carcinoma of the buccal mucosa, with flap necrosis. (c) Picture of nasopharyngeal airway (NPA) in nasopharynx. (d) V Muller Carroll tendon tunnelling forceps and the retrieved NPAA split NPA of size 7 was inserted in a more patent right nostril and secured with a towel clip [Figure 2]. The NPA was placed just enough to bypass the nasal cavity. Fibreoptic bronchoscope (FOB) was passed through the NPA once the glottis was visualised; before railroading the ET tube, we planned to remove the NPA, which was unexpectedly found missing. It could not be located while taking out the FOB.Figure 2: A split nasopharyngeal airway with a towel clip attached to it for securing it at the nostrilWhen FOB was passed through the opposite nostril, the NPA was found to be in the nasopharynx, folded on itself horizontally, occupying the available space [Figure 1c]. Despite multiple attempts to retrieve the NPA using simple blunt Magill’s forceps under FOB guidance, the procedure was unsuccessful due to restricted access. Finally, V Muller Carroll Tendon tunnelling forceps, a plastic surgery instrument [Figure 1d], was used to retrieve the NPA. The instrument was passed through the primary nostril where the NPA was placed, and under direct visualisation using FOB, the NPA was successfully retrieved by holding its flange. The patient remained sedated yet responsive throughout the ordeal, maintaining adequate oxygenation levels. This incident highlights the crucial importance of securing the NPA, particularly in patients with limited mouth opening, to prevent potentially life-threatening complications.[2,3] The case also emphasises the necessity for healthcare providers to be aware of alternative retrieval methods and to have access to appropriate tools in challenging situations. Proper fixation of the NPA and awareness of retrieval techniques are essential components of safe airway management, especially when conventional methods are insufficient. In conclusion, the successful retrieval of the NPA highlights the importance of meticulous planning, prompt action and effective communication amongst the surgical team. By addressing the challenges of difficult airways, healthcare providers can ensure optimal patient outcomes and mitigate the risks associated with airway management procedures. Consent statement Written informed consent was obtained from the patient for the publication of this case report and accompanying image. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Author contributions Darshana Rathod- Conceptualisation, revision and final draft, Kamlesh Kumari- conceptualisation, revision and final draft, Vidhyadhari- Writing initial draft, revisions. Swati Ojha- Writing initial draft, and revisions. Disclosure of use of artificial intelligence (AI)-assistive or generative tools Used for checking grammar.