Pharyngeal wall perforation — an unusual complication of blind intubation with a gum elastic bougic

The gum elastic bougie is useful to intubate patients with a difficult airway, especially when the vocal cords are not visible at laryngoscopy. It has been suggested that blind placement of the bougie in the trachea can be confirmed by the ‘click’ sign due to the tip of the bougic sliding over the tracheal cartilages and the ‘hold-up’ sign due to interruption of advancement of the bougie through a small bronchus [1]. It has also been recommended that hold-up usually occurs between 20 and 40 cm and is present in all cases but should only be sought if the click is absent [2]. We wish to report a complication of blind placement of the bougie which we believe has not been previously reported. A 64-year-old man underwent partial glossectomy, radical neck dissection and a radial forearm free flap for carcinoma of the tongue. After an uneventful anaesthetic with oxygen, nitrous oxide, isoflurane and morphine, he was extubated in the recovery room when fully awake. He maintained spontaneous respiration with arterial saturation of above 97% and an unobstructed airway for about 1 h postoperatively when his breathing became laboured and saturation fell to less than 90% despite 100% inspired oxygen. An increasing haematoma in the neck was diagnosed as the cause of his respiratory obstruction and a decision was made to reintubate him with a view to surgical exploration. Induction was commenced with sevoflurane in 100% oxygen and ability to manually ventilate the lungs confirmed. Direct laryngoscopy revealed blood in the oropharynx which, despite suctioning, did not reveal any view of the larynx. A gum elastic bougie was blindly inserted in the midline with the laryngoscope blade lifting the pharyngeal structures. There was no ‘click’ but a ‘hold-up’ occurred at about 25 cm. A 6-mm cuffed tracheal tube was railroaded over the bougie but ventilation proved difficult and absence of end-tidal carbon dioxide and air entry confirmed that the tube was not in the trachea. The tracheal tube was removed and the patient's lungs manually ventilated again. The anaesthetic nurse commented on the presence of subcutaneous crepitus in the region of the neck wound. A second attempt at blindly inserting the bougie into the trachea revealed a ‘click’ and the tracheal tube was successfully railroaded into the trachea and its position confirmed. At surgical exploration, the surgeon commented on the presence of a perforation in the lateral wall of the pharynx near the anastomosis of the free flap. A bougie was passed through the mouth and it passed easily into this hole (figure), demonstrating that it had been made by the first blind attempt at intubation. The ‘hold-up’ may have been due to obstruction of the smooth passage of the bougie through the tissues. This case has demonstrated an unusual complication of blind placement of a bougie. We feel that the presence of the ‘hold-up’ sign alone in the absence of click may not be enough to suggest tracheal placement especially in patients who have had surgery around the oropharynx.