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Armored tubes: An unusual chink in armor!

Armored tubes or flexometallic cuffed endotracheal tubes (FMCETTs) have a metallic or nylon spiral reinforcing wire enclosed on both interior and exterior by rubber, polyvinyl chloride (PVC), latex, or silicone.[1‐3] The most common reported cause of FMCETT obstruction is kinking caused by loosening of reinforcing spiral due to ethylene oxide sterilization/reuse and tube bite.[2‐4] We report an unusual leak in the armored tube whose timely detection saved a 60‐year‐old female posted for right maxillectomy and pectoralis major myocutaneous flap reconstruction for carcinoma right retromolar trigone, from airway catastrophe. All her incisors were extremely loose and were secured with sterile silk thread knotted around each tooth and firmly taped to the cheek. She had a short neck with a receding mandible. Her mentohyoid distance was 4 cm. An irremovable gold nose pin adorned her left nostril. Her nostrils were prepared with xylometazoline drops. Anesthesia was induced with intravenous fentanyl 100 μg, propofol 70 mg, and atracurium 40 mg. A C‐Mac D‐blade videolaryngoscope[5] was utilized anticipating a difficult airway. A 7 mm internal diameter FMCETT was inserted endotracheally through the left nostril. Rotating maneuvers, FMCETT cuff inflation, and neck flexion failed to facilitate intubation. A Bodecker’s forceps were used to grasp the FMCETT and negotiate it through the glottis. After auscultatory and capnographic confirmation of FMCETT placement, a nasogastric tube was inserted through the right nostril and oropharyngeal packing was done. Anesthesia was maintained with bispectral index‐guided propofol infusion, desflurane 2%–4%, oxygen 40%, medical air 60%, morphine 6 mg, fentanyl in hourly boluses of 20 μg, and a peripheral nerve stimulator‐guided atracurium infusion.