Discussion

Accidental damage to the ETT is a rare but potentially life-threatening intraoperative complication most commonly encountered during head and neck and maxillofacial surgeries. These procedures involve a shared surgical-anesthetic airway and frequently require the use of powered instruments in close proximity to the airway, increasing the risk of inadvertent ETT injury [10,11].

Genioplasty poses a particular risk because the osteotomy is performed in the anterior mandible adjacent to the floor of the mouth and oral cavity, where the ETT may lie relatively unprotected. Limited working space, reduced visibility due to blood and irrigation fluids, and the use of oscillating saws further contribute to airway vulnerability [6].

Mechanisms of ETT injury reported in the literature include partial or complete transection by oscillating saws, osteotomes, rotary drills, and sharp retractors. Thermal injury from electrocautery and compression-related tube deformation have also been described [7,12]. Partial ETT damage is particularly hazardous because ventilation may initially appear adequate, delaying recognition until hypoventilation or hypoxia occurs [13].

Early recognition of ETT compromise is essential. Sudden reductions in tidal volume, audible air leak, altered capnography waveform, difficulty in ventilation, and unexpected oxygen desaturation are key warning signs. Continuous capnography is especially valuable, often indicating abnormalities before hypoxia develops [14]. Prompt communication between anesthetic and surgical teams is critical, and airway security must take precedence over surgical progress. Immediate suctioning and oral cavity packing reduce aspiration risk before airway intervention [15].

Management depends on the extent of tube damage and the patient's ventilatory status. Controlled tube exchange using direct or video laryngoscopy with a bougie or airway exchange catheter may be successful. However, anesthesiologists must be prepared for an emergency surgical airway if reintubation fails, particularly in the presence of bleeding and limited access [8,15].

Airway management for orthognathic surgery must reconcile secure ventilation with unobstructed surgical access. Nasotracheal intubation remains the standard approach, while oral intubation with submental conversion is a recognized alternative when a nasal tube would compromise the operative field or when concurrent nasal work is planned; tracheostomy is reserved for prolonged or complex reconstructions [3-5]. Instrument-related ETT injury is an uncommon but repeatedly reported complication of these procedures, with partial and complete transection following the use of oscillating and reciprocating saws, rotary drills, and Gigli saws during orthognathic and maxillary osteotomies [6-8]. Reinforced flexometallic tubes resist compression and kinking but, as in the present case, do not reliably withstand a direct strike from a powered saw. Associated intraoperative airway challenges include accidental extubation, tube kinking, cuff perforation, aspiration of blood and irrigation fluid, airway edema, and difficult reintubation, any of which may compound the primary injury and must be anticipated by the anesthetic team [7,12].

Several measures may reduce the risk of ETT injury during genioplasty and related osteotomies. The submentally routed tube segment should be shielded from the saw with a retractor or malleable protector, and its position confirmed immediately before each saw activation. Osteotomy depth should be controlled and the lingual cortex engaged under direct vision; where available, piezoelectric instrumentation, which cuts mineralized bone but spares soft tissue and the tube, offers an inherently safer alternative to conventional saws for cuts adjacent to the airway. Continuous capnography and close monitoring of ventilation parameters remain indispensable, as they frequently signal tube compromise before hypoxia develops [13,14], and the surgical and anesthetic teams should share an explicit, rehearsed plan for rapid tube exchange should injury occur [15].

This case illustrates how a routine orthognathic procedure can escalate within seconds into a critical anesthetic emergency, and how structured vigilance converts a potential catastrophe into a recoverable event. It also underscores that such injuries are largely preventable through simple, deliberate safeguards rather than reliance on chance.