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Year : 2014  |  Volume : 58  |  Issue : 2  |  Page : 222-223  

An unusual cause of upper airway obstruction in a child during general anaesthesia

Department of Anaesthesiology, Critical Care and Pain Medicine, R.G. Kar Medical College and Hospital, Kolkata, West Bengal, India

Date of Web Publication16-Apr-2014

Correspondence Address:
Sugata Dasgupta
Flat B2, Ranjani Apartments, 8 M, Baishnabghata Byelane, Kolkata - 700 047, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5049.130844

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How to cite this article:
Dasgupta S, Das S, Bhattacharya D, Agarwal S. An unusual cause of upper airway obstruction in a child during general anaesthesia. Indian J Anaesth 2014;58:222-3

How to cite this URL:
Dasgupta S, Das S, Bhattacharya D, Agarwal S. An unusual cause of upper airway obstruction in a child during general anaesthesia. Indian J Anaesth [serial online] 2014 [cited 2021 Apr 14];58:222-3. Available from: https://www.ijaweb.org/text.asp?2014/58/2/222/130844


A 10-year-old girl, 130 cm tall, weighing 30 kg and belonging to a low socio-economic status, was brought to the emergency operation theatre for emergency appendicectomy for acute appendicitis. History was otherwise unremarkable. She belonged to American Society of Anaesthesiologists physical status I and her airway (Mallampati) grade was I. Her vital parameters were normal for her age with oxygen saturation (SpO 2 ) of 99% in room air. During induction of general anaesthesia, difficulty was faced during mask ventilation after succinylcholine administration together with stridor, inadequate chest movement and breath sounds, followed by desaturation. Prompt laryngoscopic examination revealed a brown elongated worm moving towards the glottis opening. The worm was immediately removed using Magill's forceps [Figure 1]. SpO 2 quickly returned to normal with normal auscultatory findings. Repeat laryngoscopy after intubation (6 mm ID cuffed endotracheal tube [ETT]) revealed a second worm migrating out of the oesophagus and was removed. The rest of the surgery was uneventful, the patient was successfully reversed, extubated and sent to ward. The worm was later identified to be roundworm or Ascaris lumbricoides. Deworming was done afterwards with a single per oral dose of tablet- albendazole 400 mg.
Figure 1: Adult Ascaris being taken out after laryngoscopy

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She had no history of ascariasis worm expulsion or respiratory symptoms due to this. Infestation by nematode A. lumbricoides is still endemic in various parts of the world. Population at risk include a low socio-economic status, suboptimal sanitation, poor personal hygiene affecting mainly children and malnourished individuals and is acquired through ingestion of embryonated eggs. [1] Deposition of adult worms in the lungs or respiratory tract is not a part of the life cycle. Adult worms may migrate towards the oesophagus and enter airways, especially under the influence of general anaesthetics [2] when swallowing and cough reflexes are obtunded. In the present case, this was likely to be assisted by (i) relaxation of lower oesophageal sphincter giving an opening to the worm to escape from rising intragastric pressure due to succinylcholine [3] (ii) horizontal positioning (iii) lack of swallowing reflex (iv) decreased gastric acid release due to H2 blockers premedication. A. lumbricoides infestation may be associated with pulmonary infiltrates with eosinophilia and potential intra-operative bronchospasm also forms an important anaesthesia consideration. [4],[5]

In a previously reported case, the worm was pushed into the larynx during nasotracheal intubation in a child with burn injuries nearly occluding the end of ETT, identified on fibreoptic bronchoscopy and was suctioned out. [6] In another case, a child with head injury intubated with an uncuffed tube had difficulty during weaning from ventilator as the worm sat at the carina obstructing both bronchi, which was removed with the help of a rigid bronchoscope. [1] Airway obstruction and desaturation due to Ascaris has also been reported in an adult polytrauma patient on ventilation in intensive care unit (ICU) and the path of entry was presumed to be around a loosely fitted ETT cuff. [7]

In patients, particularly children, residing in areas endemic for ascariasis, airway obstruction during anaesthesia or in mechanically ventilated ICU patients with uncuffed ETTs or loosely fitted cuffs should lead to a high index of suspicion for obstruction by a migrating roundworm blocking the airway. Post-operative plain radiographs of abdomen or ultrasound may help in diagnosing intestinal ascariasis. This would mandate vigilant monitoring for potential post-operative recurrence of airway obstruction and prompt anti-helminthic treatment as would in the case of a high pre-operative eosinophil count.

   References Top

1.Noerdin S, Basri MN. Acute airway obstruction due to Ascaris lumbricoides in a ventilated child. Int Med J Malaysia 2002;1:1-3. Available from: http://www.eimjm.com/Vol1-No1/Vol-No1-D1.html. [Last accessed on 2013 Mar 02].  Back to cited text no. 1
2.Weiss ST. Parasites and asthma/allergy: What is the relationship? J Allergy Clin Immunol 2000;105:205-10.  Back to cited text no. 2
3.Yilmaz H, Turkdogan MK, Akdeniz H, Kati I, Demiroz AP. Ascaris lumbricoides in the oral cavity: A case report. East J Med 1998;3:75-6.  Back to cited text no. 3
4.Vijayan VK. Tropical parasitic lung diseases. Indian J Chest Dis Allied Sci 2008;50:49-66.  Back to cited text no. 4
5.Malde AD, Pethkar TS, Tandelkar AS. In: Gandhi MN, Malde AD, Kudalkar AG, Karnik HS, editors. Anesthesia for Neonatal and Pediatric Abdominal Emergencies. A Practical Approach to Anesthesia for Emergency Surgery. 1 st ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2011. p. 345-70.  Back to cited text no. 5
6.Bailey JK, Warner P. Respiratory arrest from Ascaris lumbricoides. Pediatrics 2010;126:e712-5.  Back to cited text no. 6
7.Bharati SJ, Chowdhury T, Goyal K, Anandani J. Airway obstruction by round worm in mechanically ventilated patient: An unusual cause. Indian J Anaesth 2011;55:637-8.  Back to cited text no. 7
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