European Journal of Anaesthesiology 1999, 16, 201–203 CASE REPORT A serious anaesthetic complication of a Lefort I osteotomy S. J. Hosseini Bidgoli*, L. Dumont*, M. Mattys*, C. Mardirosoff* and P. Damseaux† Departments of *Anaesthesiology and †Stomatology, Brugmann University Hospital, Place Van Gehuchten no.4, 1020 Brussels, Belgium Summary difficulties. The management of this problem and a brief review of the literature are presented. We report a case of surgical transsection of the naso- endotracheal tube during a Lefort I maxillary os- Keywords: Maxillary osteotomy; naso-endotracheal intubation; tube cut. teotomy, resulting in severe intra-operative ventilatory Case report Thirty minutes after the beginning of surgery, just after the section of the lateral nasal wall, the surgeon An 18-year-old ASA II woman was admitted to our noticed a small bubbling in the back of the throat institution for a forward osteotomy of the maxilla without loss of pressure in the anaesthetic system. according to Lefort I and mandibular sagittal split. The The integrity of the cuff was checked and confirmed, patient’s past history was unremarkable except for a but bubbling persisted. After a repeat deflation of the bilateral labio-palatine cleft subject to many oper- cuff, the tube was pushed 1 cm down into the trachea, ations. and the cuff was reinflated with immediate cessation The preoperative physical examination, blood tests, of the bubbling. This manoeuvre was accompanied chest X-ray and ECG were normal. She did not present after a few minutes by a decrease in oxygen saturation. any signs of difficult intubation despite her maxillo- The lung auscultation was asymmetrical and revealed facial abnormalities. She was not taking any med- a selective right bronchial intubation. The inspired ication. Following premedication with midazolam, she oxygen was then increased to 100%, and the tube was was anaesthetized with propofol, sufentanil, atra- cautiously removed 1 cm. The oxygen saturation and curium, N 2 O/O 2 (60:40) and isoflurane. the auscultation returned to normal, and the bubbling The monitoring included a double-channel ECG, a did not appear again. The operation resumed and, non-invasive blood pressure, a pulse oximeter and a after 10 min, the surgeon performed the Lefort I down- capnograph. Phenylephrine 1% was instilled into the fracture with an unguarded osteotome. Bubbling re- right nostril before nasotracheal intubation. A pre- appeared, this time with a loss of pressure in the formed nasal endotracheal tube (Portex, North Nasal, anaesthetic circuit, and it was impossible to ventilate 7.00 mm internal diameter) was chosen for nasal in- the patient adequately because of the air leak. The tubation not to intrude on the surgical field. After capnograph continued to indicate expiratory CO 2 out- introduction of the preformed tube through the nose, flow, confirming the intratracheal positioning of the the trachea was easily intubated under direct vision tube. In the face of progressive arterial desaturation without any use of forceps. The cuff was inflated with despite 100% inspired O 2 , it was decided to replace 5 mL of air, and the patient was ventilated 12 times the tube. After thorough suctioning of the oropharynx, per minute with a tidal volume of 10 mL kg -1 . a nasogastric tube was inserted far into the naso- tracheal tube, the tracheal tube was withdrawn and a Accepted October 1998 Correspondence: S. J. Hosseini Bidgoli. new tracheal tube was inserted through the same  1999 European Academy of Anaesthesiology 201