Users Online: 677 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 


RSACP wishes to inform that it shall be discontinuing the dispatch of print copy of JOACP to it's Life members. The print copy of JOACP will be posted only to those life members who send us a written confirmation for continuation of print copy.
Kindly email your affirmation for print copies to dranjugrewal@gmail.com preferably by 30th June 2019.

 

 
Table of Contents
CASE REPORT
Year : 2012  |  Volume : 28  |  Issue : 2  |  Page : 247-248

"Blow-torch phenomenon" during laser assisted excision of a thyroglossal cyst at the base of the tongue


1 Department of Anaesthesiology, AJ Medical College, Mangalore, Karnataka, India
2 Department of Anaesthesiology, KVG Medical College,Sullia, Karnataka, India

Date of Web Publication11-Apr-2012

Correspondence Address:
Anitha G Bhat
"Anugraha", Kadri Kambla, Mangalore, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.94911

Rights and Permissions
  Abstract 

We report a case of blow-torch phenomenon encountered during diode laser assisted excision of a thyroglossal cyst in a child. This is first such case report from India and highlights an unusual complication which anesthesiologists need to be aware of due to the increasing use of operative laser.

Keywords: Blow-torch phenomenon, diode laser, thyroglossal cyst-base of the tongue


How to cite this article:
Bhat AG, Ganapathi P. "Blow-torch phenomenon" during laser assisted excision of a thyroglossal cyst at the base of the tongue. J Anaesthesiol Clin Pharmacol 2012;28:247-8

How to cite this URL:
Bhat AG, Ganapathi P. "Blow-torch phenomenon" during laser assisted excision of a thyroglossal cyst at the base of the tongue. J Anaesthesiol Clin Pharmacol [serial online] 2012 [cited 2019 Sep 21];28:247-8. Available from: http://www.joacp.org/text.asp?2012/28/2/247/94911


  Introduction Top


Blow-torch phenomenon is a known complication during of laser surgery. It is caused by ignition of anesthetic gases induced by a laser beam. It is seen with the use of lasers that do not make use of optical fibers for laser beam delivery, such as carbon-dioxide (CO 2 ) lasers which use articulated arm technology. Diode lasers have replaced CO 2 lasers today. They have optical fibers for delivery of the laser at the site of surgery, facilitating more precision and control.


  Case Report Top


A 7-year-old boy was admitted for excision of a cystic swelling at the posterior aspect of the base of the tongue a few centimeters anterior to the valleculae. The smallest laser endotracheal tube (ETT) available was of 7-mm outer diameter (OD) and an internal diameter of 5.5 mm. After induction of anesthesia with propofol, followed by administration of suxamethonium intravenously (IV), nasotracheal intubation was done with this tube. Anesthesia was maintained oxygen in air, atracurium, intermittent boluses of propofol, and fentanyl IV. Throat was packed with saline-soaked roller gauze.

The saline-soaked throat pack was obstructing the field of vision of the surgeon and also restricting the outward pull of the tongue as cyst was large (3 × 3 cm) and placed posteriorly. The throat pack was removed to facilitate surgery. The surgeon assured that adequate precautions would be taken to avoid bringing the diode laser delivery handle tip in contact with the ETT. Toward the end of the surgical laser excision, the tip of the handle accidently slipped and touched the ETT. We heard a very short "pop" like noise which lasted for about 1-2 s. The exhaled gas from the expiratory valve also smelt of smoke for about a minute or so. There was however no change in hemodynamics, drop in SpO 2 or reduction in air entry/chest expansion. We discontinued oxygen and ventilated with air. As the surgery had been completed and we were able to ventilate the lungs, we reversed the neuromuscular blockade. A small dose of IV steroid dexamethasone (4 mg IV) was given. After tracheal extubation, a flexible laryngopharyngoscope was passed to visualize the trachea up to the carina and fortunately everything appeared to be normal.

The removed ETT [Figure 1] had a very small circular hole and the inner aspect of the tube was black distal to the hole [Figure 2]. The cuff was intact but the tubing from the pilot balloon to the cuff was damaged, which is typically seen in "interior blow-torch phenomenon." Patient recovered well and was shifted to postoperative, ward, monitored and given humidified oxygen and discharged next day.
Figure 1: Endotracheal tube showing the charred aspect

Click here to view
Figure 2: Inset of charred region

Click here to view



  Discussion Top


Diode lasers are used with low power setting and do not usually cause perforation or damage to polyvinyl chloride (PVC) ETT coming in direct contact. Though studies have shown silicon and red rubber tubes to be more resistant to ignition compared to PVC, some studies have reported that PVC is less flammable than silicon or red rubber, having a flammability index of 0.26 vs. 0.19 for silicon and red rubber, respectively. [1] Use of laser resistant material wrapped around PVC ETT or double-cuffed silicon-coated ETT is however more safe. [2],[3] We did not use it due to nonavailability but rather used a PVC ETT. Laser-resistant ETT are bulkier and more rigid than conventional ETT and thus need careful insertion to prevent mucosal abrasions.

In the event of a blow-torch phenomenon, upper airways are usually involved. Inhalation of smoke can cause chemical injury, bronchospasm, and respiratory failure. PVC tubes burn more vigorously and hydrochloric acid may be produced, which is a pulmonary toxin. In case of such an airway fire, oxygen should be temporary discontinued, damaged ETT removed, trachea reintubated with a fresh ETT, and the pharynx flushed with cold saline. A rigid or fiberoptic bronchoscopy examination should be done to look for damage and pieces of burned ETT. Humidified oxygen, steroids, and antibiotics must be administered and at times controlled ventilation and tracheostomy may become necessary. [1] Postoperatively, patient should be intensively monitored and a chest X-ray should be taken.

Surgeons must ensure that laser energy is not reflected from smooth metal surfaces or directed at sensitive structures. Applying protective metal foil wraps to ETT, such as aluminum or copper has been advocated. [3],[4],[5] The ETT cuff can be filled with colored saline and placed far distally in trachea and the visible cuff covered with moistened cotton pledgets, which should be remoistened as needed. Laser resistant tubes are available for use during laser surgery. To reduce the obstruction in the surgical field, by airway instruments, even techniques of spontaneous ventilation or intermittent apnea with intravenous anesthetics have been used. [6] Clear communication must be ensured and protocols followed to manage and avert such crisis.

 
  References Top

1.Rampil IJ. Anesthesia for Laser Surgery. In: Miller RD, editor. Miller's Anesthesia. 7 th ed. Philadelphia: Churchill Livingstone Elsevier; 2010. p. 2409.  Back to cited text no. 1
    
2.Hermens JM, Bennett MJ, Hirschman CA. Anesthesia for laser surgery. Anesth Analg 1983;62:218-29.  Back to cited text no. 2
    
3.Emergency Care Research Institute. Laser-Resistant endotracheal tubes and wraps. Health Devices 1990;19:112.  Back to cited text no. 3
    
4.Sosis MB. Evaluation of 5 metallic tapes for protection of endotracheal tubes during CO 2 laser Surgery? Anesth Analg 1989;68:392-3.  Back to cited text no. 4
    
5.Sosis MB, Dillon F. What is the safest foil tape for endotracheal tube protection during Nd-YAG laser surgery? A comparative study. Anesthesiology 1990;72:553-5.  Back to cited text no. 5
    
6.Best C. Anesthesia for laser surgery of the airway in children. Pediatric Anesthesia 2009;19(Suppl 1):155-65.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
1 Transoral robotic excision of a lingual thyroglossal duct cyst
Stephanie Fong,John-Charles Hodge,Andrew Foreman,Suren Krishnan
Journal of Robotic Surgery. 2017;
[Pubmed] | [DOI]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
   Abstract
  Introduction
  Case Report
  Discussion
   References
   Article Figures

 Article Access Statistics
    Viewed1601    
    Printed84    
    Emailed1    
    PDF Downloaded266    
    Comments [Add]    
    Cited by others 1    

Recommend this journal