Risk of inappropriate fixation position for patients with cleft lip and palate after head and neck extension

Risk of inappropriate fixation position for patients with cleft lip and palate after head and neck extension | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Risk of inappropriate fixation position for patients with cleft lip and palate after head and neck extension Masanori Tsukamoto, Kazuya Matsuo, Takeshi Yokoyama, Kazuhiro Hano, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3789505/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Preformed oral tubes are preferred in clinical practice due to airway patency for enough operative fields during procedures. However, as the tube moves away from the carina during neck extension performed for procedures following intubation, the tracheal tube cuff may compress the vocal cords and potentially cause balloon-induced injury. In this study, we retrospectively investigated the incidence of tube replacement after procedures involving head and neck extension. We retrospectively investigated pediatric patients (6–15 years) who underwent oral surgery. Intubation was performed using a cuffed 5.0–7.5 mm ID RAE oral tube. Patients were subsequently positioned with a hyperextended neck for surgical procedures. The tube cuff position was reconfirmed by video laryngoscope, and the tube was replaced by a wire-reinforced tube. This retrospective study included 185 patients. We observed no intraoperative respiratory complications in this study. Among 186 patients, 16 (8%) underwent tube replacement owing to inaccurate cuff position after neck extension. Fixation of the lower lip in RAE tube was 17.9 ± 1.8 cm, which was not significantly different from values using wired-reinforced tracheal tubes 18.9 ± 2.3 cm. We observed that inappropriate tube positioning after head and neck extension occurred in 16 patients (8%). Anesthesiologists should closely monitor and confirm the position of the tube cuff for safe airway management. Health sciences/Anatomy Health sciences/Medical research Health sciences/Risk factors oral intubation RAE tube wire-reinforced tracheal tube general anesthesia. Introduction Cleft lip and palate are orofacial deformities that require surgical repair using methods such as iliac bone grafting and correction of external nasal deformities in childhood to promote speech development and facial growth and to improve aesthetics ( 1 – 3 ) . In such cases, preformed oral tubes are frequently introduced under general anesthesia to secure the patient’s airways ( 4 , 5 ) . Ring-Adair-Elwyn (RAE) tracheal tubes are preferred in clinical practice due to airway patency for enough operative fields during procedures ( 6 , 7 ) . The position of the cuff and tube tip within the trachea is predetermined in preformed tracheal tubes because the bend in the tube is placed with the center of its concave curvature facing the lower incisors or alveolar ridge ( 8 ) . However, as the tube moves away from the carina during neck extension performed for procedures following intubation, the tracheal tube cuff may compress the vocal cords and potentially cause balloon-induced injury ( 9 ) . The position of the tube cuff is confirmed by visual observation after the backbend is completed. An inappropriately placed tube cuff necessitates tube replacement. Previous studies have reported movement of the tube away from the carina after head and neck extension; however, no study has reported tube replacement in any patient ( 8 , 9 ) . In this study, we retrospectively investigated the incidence of tube replacement after procedures involving head and neck extension. Methods Study design and ethics statement We retrospectively investigated pediatric patients (6–15 years) who underwent surgery for treatment of cleft lip and palate between March 2012 and 2023, following approval from the Ethics Review Board of Kyushu University Hospital (Approval No.23031-00 on April 25, 2023) that waived the need for individual consent. General anesthesia was induced using sevoflurane or propofol, atropine, remifentanil, and fentanyl. Oral intubation facilitated by rocuronium was performed using direct or video laryngoscopy. Patients were placed in the supine position with their head resting on a pillow. Intubation was performed using a cuffed 5.0–7.5 mm ID RAE oral tube (Portex, Smiths Medical Japan), sized using the formula for age, height, or weight. ( 10 , 11 ) After confirming successful endotracheal tube positioning (proper cuff position based on direct vision and auscultation), the tube cuff was inflated with air to maintain a pressure of 15–25 cm H 2 O. The tube was taped to the center of the lower lip and fixed in the midline of the mandible. Patients were placed in an anatomically neutral position. Inhalational anesthetics or propofol, remifentanil plus oxygen/air were used at the anesthesiologist’s discretion. Patients were subsequently positioned with a hyperextended neck for surgical procedures. The tube cuff position was reconfirmed by video laryngoscope, and the tube was replaced by a wire-reinforced tube (Safety-Flex Cuffed Tracheal Tube, Mallinckrodt, Athlone, Ireland). We recorded cases in which inappropriate tube position (tube partially visible or partially over the glottis) necessitated tube replacement. Furthermore, we compared the distance from the lower lip to the tube tip between the RAE and wire-reinforced tube groups. Statistical analysis Demographic data and tube replacement rates were presented as mean ± standard deviation and analyzed using the Student t-test. Chi-square analysis was used to compare data. P value < 0.05 was considered statistically significant. Results This retrospective study included 185 patients. We observed no intraoperative respiratory complications in this study (Table.1). Among 186 patients, 16 (8%) underwent tube replacement owing to inaccurate cuff position after neck extension. Fixation of the lower lip in RAE tube was 17.9 ± 1.8 cm, which was not significantly different from values using wired-reinforced tracheal tubes 18.9 ± 2.3 cm (Table.2). Discussion In this study, inappropriate tube positioning after head and neck extension occurred in 16 patients (8%). We observed no significant differences in the distance at fixed position between the RAE and wire-reinforced tube. Tube fixation for procedures such as iliac bone grafting and correction of external nasal deformities is performed using tubes taped to the center of the lower lip in the midline of the mandible because these surgeries involve tube fixation using the Dingman gag with tongue depressor. ( 13 , 14 ) Furthermore, it should be symmetrical for aesthetic procedures; therefore, a tube centered at the lower lip is important for an unrestricted surgical field for easy maneuverability. Owing to its preformed U-shaped curve, the RAE tube was our first choice; the tube fits better into an oral gag, is easier to secure to the lower lip, and reduces the risk of unintended extubation. Although the preformed curve of the RAE tube ensures airway patency without the risk of dislodgement secondary to elastic recoil, the ability to adjust the intubation depth of the preformed RAE tubes is limited owing to the preformed U-shaped curve, and insertion length is fixed based on the internal diameter of each tube. ( 6 , 7 ) During neck extension (which is necessary for optimal visualization of the operative field) after intubation, as the tube moves away from the carina, the tube cuff may compress the vocal cords and potentially cause both temporary or permanent vocal fold paralysis. ( 9 , 15 ) This could result in variable tube positions, which may be exacerbated during head and neck movement. ( 9 , 16 ) Therefore, preformed RAE tubes are associated with a high risk of inadvertent tube malpositioning. It is important to check the position of the tube cuff using video or direct laryngoscopy after neck extension, and the tube should be replaced in cases in which the tube cuff is partially visible or partially covers the glottis. In such cases, we recommend the use of a wire-reinforced tube to reduce the tube replacement rate. ( 12 , 17 , 18 ) Wire-reinforced tube tolerate extreme flexion without kinking at any site and can withstand high pressure without collapsing, which serve as advantages of this device. However, the tension of the intraorally curved wire-reinforced tube may obstruct the operator’s vision, which represents a disadvantage. Furthermore, the fixed position at the lower lip tends to be a longer distance than that using the RAE tube. ( 6 , 7 ) Therefore, a wire-reinforced tube is not preferred as the first choice. Following are the limitations of this study: (a) We observed no intraoperative tube complications; however, the position of the tube tip was not confirmed using a fiberoptic scope. Therefore, tube replacement was exclusively performed at the anesthesiologist’s discretion. (b) The retroflexion angle by a surgeon varies depending upon a patient’s physique and the surgical technique used. We could not measure retroflexion angles in this study. Conclusion We observed that inappropriate tube positioning after head and neck extension occurred in 16 patients (8%). Anesthesiologists should closely monitor and confirm the position of the tube cuff for safe airway management. Declarations Author Contribution M. Tsukamoto and T. Yokoyama contributed to the conception, design, data acquisition, drafted and critically revised the manuscript. K. Hano and M. Eto contributed to data acquisition, interpretation and revised the manuscript. K. Matsuo contribute to perform the statistical analyses.T. Yokoyama contributed to the conception, interpretation and revised the manuscript. All authors gave their final approval and agreed to be accountable for all aspects of the work. All authors have read and approved the final manuscript. Ethics approval: This retrospective observational study protocol was approved by Ethics Review Board of Kyushu University Hospital (Approval No.23031-00 on April 25, 2023). All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Consent for publication; Not applicable. Availability of data and materials; The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests; The authors declare that they have no competing interests. Funding; This research did not receive any specific grant from funding agencies in the public, commercial. Acknowledgements; Not applicable Declarations of interest; The authors declare that they have no conflicts of interest. References Kumar N, Dubey PK, Nupoor N, Kumar A, Haq A, A simple technique to reinforce kinked South Pole RAE tracheal tube, J Clin Monit Comput, 2021;35(4):955-956. Ahn JH, Park JH, Kim MS, Kang HC, Kim IS, Point of care airway ultrasound to select tracheal tube and determine insertion depth in cleft repair surgery, Sci Rep, 2021, 26;11(1):4743. Black AE, Mackersie AM, Accidental bronchial intubation with RAE tubes, Anaesthesia, 1991;46(1):42-3. Jordi Ritz EM, Von Ungern-Sternberg BS, Keller K, Frei FJ, Erb TO, The impact of head position on the cuff and tube tip position of preformed oral tracheal tubes in young children, Anaesthesia, 2008;63(6):604-9. Kundra P, Supraja N, Agrawal K, Ravishankar M, Flexible laryngeal mask airway for cleft palate surgery in children: a randomized clinical trial on efficacy and safety, Cleft Palate Craniofac J, 2009;46(4):368-73. Weiss M, Dullenkopf A, Böttcher S, Schmitz A, Stutz K, Gysin C, Gerber AC, Clinical evaluation of cuff and tube tip position in a newly designed paediatric preformed oral cuffed tracheal tube, Br J Anaesth, 2006;97(5):695-700. Jin SJ, Choi YJ, Park SW, Lee YM, Correlation between changes in thyromental distance and distance of migration of oral Ring-Adair-Elwyn tubes during neck extension with a shoulder positioner in patients undergoing neck procedures, J Int Med Res, 2015;43(3):460-7. Kim HY, Kim EJ, Shin CS, Kim J, Shallow nasal RAE tube depth after head and neck surgery: association with preoperative and intraoperative factors, J Anesth, 2019;33(1):118-124. Yamanaka H, Tsukamoto M, Hitosugi T, Yokoyama T, Changes in nasotracheal tube depth in response to head and neck movement in children, Acta Anaesthesiol Scand, 2018 ;62(10):1383-1388. Tsukamoto M, Yamanaka H, Yokoyama T, Predicting the appropriate size of the uncuffed nasotracheal tube for pediatric patients: a retrospective study, Clinical Oral Investigations, 2019,23(1), 493-495 Kohjitani A, Iwase Y, Sugiyama K, Sizes and depths of endotracheal tubes for cleft lip and palate children undergoing primary cheiloplasty and palatoplasty, Paediatr Anaesth, 2008;18(9):845-51. Deanovic D, Gerber AC, Weiss M, Repeated accidental extubation of wire-reinforced cuffed tracheal tubes in patients with cleft palate, Paediatr Anaesth, 2004;14(9):801-2. Rao LP, Peter S, Modification of the dingman mouth gag for better visibility and access in the management of cleft palate, Cleft Palate Craniofac J, 2015;52(2):250-3. Kotrashetti SM, Dube G, Thakkar B, Ahuja M, Simple Technique Overcoming a Persistent Problem in Cleft Palate Repair, J Maxillofac Oral Surg, 2016;15(4):558-559. Yoo SY, Kim JH, Han SH, Oh AY, A comparative study of endotracheal tube positioning methods in children: safety from neck movement, Anesth Analg, 2007;105(3):620-5. Kim JT, Kim HJ, Ahn W, Kim HS, Bahk JH, Lee SC, Kim CS, Kim SD, Head rotation, flexion, and extension alter endotracheal tube position in adults and children, Can J Anaesth, 2009;56(10):751-6. Dimitriou VK, Zogogiannis ID, Douma AK, Pentilas ND, Liotiri DG, Wachtel MS, Karakitsos D, Comparison of standard polyvinyl chloride tracheal tubes and straight reinforced tracheal tubes for tracheal intubation through different sizes of the Airtraq laryngoscope in anesthetized and paralyzed patients: a randomized prospective study, Anesthesiology, 2009;111(6):1265-70. Kim JT, Kim HJ, Ahn W, Kim HS, Bahk JH, Lee SC, Kim CS, Kim SD, Head rotation, flexion, and extension alter endotracheal tube position in adults and children, Can J Anaesth, 2009;56(10):751-6. Tables Table.1 Characteristics of patients (n=185). RAE tube (n=169) Wire-reinforced tracheal tube (n=16) Gender (M/F) 92/78 9/7 Age (yrs) 10.1 ± 3.9 9.3 ± 1.3 Height (cm) 135.0 ± 10.6 133.4 ± 6.3 Weight (kg) 31.4 ± 7.7 30.7 ± 6.4 Table.2 The distance from the tube tip in the mandibular midline taped to the center of the lower lip. RAE tube (n=169) Wire-reinforced tracheal tube (n=16) P value The position of the middle lower lip (㎝) 17.9 ± 1.8 18.9 ± 2.3 0.08 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3789505","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":264115655,"identity":"46821cbb-628d-4147-a250-2e9176233bf4","order_by":0,"name":"Masanori Tsukamoto","email":"data:image/png;base64,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","orcid":"","institution":"Kagoshima University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Masanori","middleName":"","lastName":"Tsukamoto","suffix":""},{"id":264115656,"identity":"7a063865-0348-4b2d-8444-b371ca0375ad","order_by":1,"name":"Kazuya Matsuo","email":"","orcid":"","institution":"Kyushu Institute of Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kazuya","middleName":"","lastName":"Matsuo","suffix":""},{"id":264115657,"identity":"427c34f6-4662-4b13-b5a5-4f4d78d170c8","order_by":2,"name":"Takeshi Yokoyama","email":"","orcid":"","institution":"Kyushu University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Takeshi","middleName":"","lastName":"Yokoyama","suffix":""},{"id":264115658,"identity":"e3e4c621-7b71-4b9f-8e09-5e156dce9374","order_by":3,"name":"Kazuhiro Hano","email":"","orcid":"","institution":"Kyushu University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kazuhiro","middleName":"","lastName":"Hano","suffix":""},{"id":264115659,"identity":"7ffe2df4-3403-4d3c-b42f-774ad694427b","order_by":4,"name":"Michi Eto","email":"","orcid":"","institution":"Kyushu University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Michi","middleName":"","lastName":"Eto","suffix":""}],"badges":[],"createdAt":"2023-12-22 02:30:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3789505/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3789505/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69500701,"identity":"df4b1c71-e526-4fb1-ae49-0f5475bf3353","added_by":"auto","created_at":"2024-11-21 05:26:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":223354,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3789505/v1/7816bb6b-41fd-48f8-a671-45f9522a4770.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk of inappropriate fixation position for patients with cleft lip and palate after head and neck extension","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCleft lip and palate are orofacial deformities that require surgical repair using methods such as iliac bone grafting and correction of external nasal deformities in childhood to promote speech development and facial growth and to improve aesthetics \u003csup\u003e(\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e. In such cases, preformed oral tubes are frequently introduced under general anesthesia to secure the patient’s airways \u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e. Ring-Adair-Elwyn (RAE) tracheal tubes are preferred in clinical practice due to airway patency for enough operative fields during procedures \u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003e. The position of the cuff and tube tip within the trachea is predetermined in preformed tracheal tubes because the bend in the tube is placed with the center of its concave curvature facing the lower incisors or alveolar ridge \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e. However, as the tube moves away from the carina during neck extension performed for procedures following intubation, the tracheal tube cuff may compress the vocal cords and potentially cause balloon-induced injury \u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e. The position of the tube cuff is confirmed by visual observation after the backbend is completed. An inappropriately placed tube cuff necessitates tube replacement. Previous studies have reported movement of the tube away from the carina after head and neck extension; however, no study has reported tube replacement in any patient \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this study, we retrospectively investigated the incidence of tube replacement after procedures involving head and neck extension.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eStudy design and ethics statement\u003c/p\u003e\u003cp\u003eWe retrospectively investigated pediatric patients (6–15 years) who underwent surgery for treatment of cleft lip and palate between March 2012 and 2023, following approval from the Ethics Review Board of Kyushu University Hospital (Approval No.23031-00 on April 25, 2023) that waived the need for individual consent.\u003c/p\u003e\u003cp\u003eGeneral anesthesia was induced using sevoflurane or propofol, atropine, remifentanil, and fentanyl. Oral intubation facilitated by rocuronium was performed using direct or video laryngoscopy. Patients were placed in the supine position with their head resting on a pillow. Intubation was performed using a cuffed 5.0–7.5 mm ID RAE oral tube (Portex, Smiths Medical Japan), sized using the formula for age, height, or weight. \u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e After confirming successful endotracheal tube positioning (proper cuff position based on direct vision and auscultation), the tube cuff was inflated with air to maintain a pressure of 15–25 cm H\u003csub\u003e2\u003c/sub\u003eO. The tube was taped to the center of the lower lip and fixed in the midline of the mandible.\u003c/p\u003e\u003cp\u003ePatients were placed in an anatomically neutral position. Inhalational anesthetics or propofol, remifentanil plus oxygen/air were used at the anesthesiologist’s discretion. Patients were subsequently positioned with a hyperextended neck for surgical procedures. The tube cuff position was reconfirmed by video laryngoscope, and the tube was replaced by a wire-reinforced tube (Safety-Flex Cuffed Tracheal Tube, Mallinckrodt, Athlone, Ireland).\u003c/p\u003e\u003cp\u003eWe recorded cases in which inappropriate tube position (tube partially visible or partially over the glottis) necessitated tube replacement. Furthermore, we compared the distance from the lower lip to the tube tip between the RAE and wire-reinforced tube groups.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDemographic data and tube replacement rates were presented as mean ± standard deviation and analyzed using the Student t-test. Chi-square analysis was used to compare data. P value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis retrospective study included 185 patients. We observed no intraoperative respiratory complications in this study (Table.1). Among 186 patients, 16 (8%) underwent tube replacement owing to inaccurate cuff position after neck extension.\u003c/p\u003e \u003cp\u003eFixation of the lower lip in RAE tube was 17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 cm, which was not significantly different from values using wired-reinforced tracheal tubes 18.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 cm (Table.2).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, inappropriate tube positioning after head and neck extension occurred in 16 patients (8%). We observed no significant differences in the distance at fixed position between the RAE and wire-reinforced tube.\u003c/p\u003e \u003cp\u003eTube fixation for procedures such as iliac bone grafting and correction of external nasal deformities is performed using tubes taped to the center of the lower lip in the midline of the mandible because these surgeries involve tube fixation using the Dingman gag with tongue depressor. \u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e Furthermore, it should be symmetrical for aesthetic procedures; therefore, a tube centered at the lower lip is important for an unrestricted surgical field for easy maneuverability. Owing to its preformed U-shaped curve, the RAE tube was our first choice; the tube fits better into an oral gag, is easier to secure to the lower lip, and reduces the risk of unintended extubation. Although the preformed curve of the RAE tube ensures airway patency without the risk of dislodgement secondary to elastic recoil, the ability to adjust the intubation depth of the preformed RAE tubes is limited owing to the preformed U-shaped curve, and insertion length is fixed based on the internal diameter of each tube. \u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003e During neck extension (which is necessary for optimal visualization of the operative field) after intubation, as the tube moves away from the carina, the tube cuff may compress the vocal cords and potentially cause both temporary or permanent vocal fold paralysis. \u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e This could result in variable tube positions, which may be exacerbated during head and neck movement. \u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e Therefore, preformed RAE tubes are associated with a high risk of inadvertent tube malpositioning. It is important to check the position of the tube cuff using video or direct laryngoscopy after neck extension, and the tube should be replaced in cases in which the tube cuff is partially visible or partially covers the glottis.\u003c/p\u003e \u003cp\u003eIn such cases, we recommend the use of a wire-reinforced tube to reduce the tube replacement rate. \u003csup\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/sup\u003e Wire-reinforced tube tolerate extreme flexion without kinking at any site and can withstand high pressure without collapsing, which serve as advantages of this device. However, the tension of the intraorally curved wire-reinforced tube may obstruct the operator\u0026rsquo;s vision, which represents a disadvantage. Furthermore, the fixed position at the lower lip tends to be a longer distance than that using the RAE tube. \u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003e Therefore, a wire-reinforced tube is not preferred as the first choice.\u003c/p\u003e \u003cp\u003eFollowing are the limitations of this study: (a) We observed no intraoperative tube complications; however, the position of the tube tip was not confirmed using a fiberoptic scope. Therefore, tube replacement was exclusively performed at the anesthesiologist\u0026rsquo;s discretion. (b) The retroflexion angle by a surgeon varies depending upon a patient\u0026rsquo;s physique and the surgical technique used. We could not measure retroflexion angles in this study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe observed that inappropriate tube positioning after head and neck extension occurred in 16 patients (8%). Anesthesiologists should closely monitor and confirm the position of the tube cuff for safe airway management.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM. Tsukamoto and T. Yokoyama contributed to the conception, design, data acquisition, drafted and critically revised the manuscript. K. Hano and M. Eto contributed to data acquisition, interpretation and revised the manuscript. K. Matsuo contribute to perform the statistical analyses.T. Yokoyama contributed to the conception, interpretation and revised the manuscript. All authors gave their final approval and agreed to be accountable for all aspects of the work. All authors have read and approved the final manuscript.\u003c/p\u003e\u003cp\u003eEthics approval:\u0026nbsp;This retrospective observational study protocol was approved by Ethics Review Board of Kyushu University Hospital (Approval No.23031-00 on April 25, 2023). All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eConsent for publication; Not applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials; The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests; The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding; This research did not receive any specific grant from funding agencies in the public, commercial.\u003c/p\u003e\n\u003cp\u003eAcknowledgements; Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDeclarations of interest; The authors declare that they have no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKumar N, Dubey PK, Nupoor N, Kumar A, Haq A, A simple technique to reinforce kinked South Pole RAE tracheal tube, J Clin Monit Comput, 2021;35(4):955-956.\u003c/li\u003e\n\u003cli\u003eAhn JH, Park JH, Kim MS, Kang HC, Kim IS, Point of care airway ultrasound to select tracheal tube and determine insertion depth in cleft repair surgery, Sci Rep, 2021, 26;11(1):4743.\u003c/li\u003e\n\u003cli\u003eBlack AE, Mackersie AM, Accidental bronchial intubation with RAE tubes, Anaesthesia, 1991;46(1):42-3.\u003c/li\u003e\n\u003cli\u003eJordi Ritz EM, Von Ungern-Sternberg BS, Keller K, Frei FJ, Erb TO, The impact of head position on the cuff and tube tip position of preformed oral tracheal tubes in young children, Anaesthesia, 2008;63(6):604-9.\u003c/li\u003e\n\u003cli\u003eKundra P, Supraja N, Agrawal K, Ravishankar M, Flexible laryngeal mask airway for cleft palate surgery in children: a randomized clinical trial on efficacy and safety, Cleft Palate Craniofac J, 2009;46(4):368-73.\u003c/li\u003e\n\u003cli\u003eWeiss M, Dullenkopf A, B\u0026ouml;ttcher S, Schmitz A, Stutz K, Gysin C, Gerber AC, Clinical evaluation of cuff and tube tip position in a newly designed paediatric preformed oral cuffed tracheal tube, Br J Anaesth, 2006;97(5):695-700.\u003c/li\u003e\n\u003cli\u003eJin SJ, Choi YJ, Park SW, Lee YM, Correlation between changes in thyromental distance and distance of migration of oral Ring-Adair-Elwyn tubes during neck extension with a shoulder positioner in patients undergoing neck procedures, J Int Med Res, 2015;43(3):460-7.\u003c/li\u003e\n\u003cli\u003eKim HY, Kim EJ, Shin CS, Kim J, Shallow nasal RAE tube depth after head and neck surgery: association with preoperative and intraoperative factors, J Anesth, 2019;33(1):118-124. \u003c/li\u003e\n\u003cli\u003eYamanaka H, Tsukamoto M, Hitosugi T, Yokoyama T, Changes in nasotracheal tube depth in response to head and neck movement in children, Acta Anaesthesiol Scand, 2018 ;62(10):1383-1388.\u003c/li\u003e\n\u003cli\u003eTsukamoto M, Yamanaka H, Yokoyama T, Predicting the appropriate size of the uncuffed nasotracheal tube for pediatric patients: a retrospective study, Clinical Oral Investigations, 2019,23(1), 493-495\u003c/li\u003e\n\u003cli\u003eKohjitani A, Iwase Y, Sugiyama K, Sizes and depths of endotracheal tubes for cleft lip and palate children undergoing primary cheiloplasty and palatoplasty, Paediatr Anaesth, 2008;18(9):845-51.\u003c/li\u003e\n\u003cli\u003eDeanovic D, Gerber AC, Weiss M, Repeated accidental extubation of wire-reinforced cuffed tracheal tubes in patients with cleft palate, Paediatr Anaesth, 2004;14(9):801-2.\u003c/li\u003e\n\u003cli\u003eRao LP, Peter S, Modification of the dingman mouth gag for better visibility and access in the management of cleft palate, Cleft Palate Craniofac J, 2015;52(2):250-3.\u003c/li\u003e\n\u003cli\u003eKotrashetti SM, Dube G, Thakkar B, Ahuja M, Simple Technique Overcoming a Persistent Problem in Cleft Palate Repair, J Maxillofac Oral Surg, 2016;15(4):558-559.\u003c/li\u003e\n\u003cli\u003eYoo SY, Kim JH, Han SH, Oh AY, A comparative study of endotracheal tube positioning methods in children: safety from neck movement, Anesth Analg, 2007;105(3):620-5.\u003c/li\u003e\n\u003cli\u003eKim JT, Kim HJ, Ahn W, Kim HS, Bahk JH, Lee SC, Kim CS, Kim SD, Head rotation, flexion, and extension alter endotracheal tube position in adults and children, Can J Anaesth, 2009;56(10):751-6.\u003c/li\u003e\n\u003cli\u003eDimitriou VK, Zogogiannis ID, Douma AK, Pentilas ND, Liotiri DG, Wachtel MS, Karakitsos D, Comparison of standard polyvinyl chloride tracheal tubes and straight reinforced tracheal tubes for tracheal intubation through different sizes of the Airtraq laryngoscope in anesthetized and paralyzed patients: a randomized prospective study, Anesthesiology, 2009;111(6):1265-70.\u003c/li\u003e\n\u003cli\u003eKim JT, Kim HJ, Ahn W, Kim HS, Bahk JH, Lee SC, Kim CS, Kim SD, Head rotation, flexion, and extension alter endotracheal tube position in adults and children, Can J Anaesth, 2009;56(10):751-6.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable.1 Characteristics of patients\u0026nbsp;(n=185).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"463\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eRAE tube (n=169)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.868250539956804%\" valign=\"top\"\u003e\n \u003cp\u003eWire-reinforced tracheal tube (n=16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eGender (M/F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003e92/78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.868250539956804%\" valign=\"top\"\u003e\n \u003cp\u003e9/7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eAge (yrs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003e10.1 ± 3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.868250539956804%\" valign=\"top\"\u003e\n \u003cp\u003e9.3 ± 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eHeight (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003e135.0 ± 10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.868250539956804%\" valign=\"top\"\u003e\n \u003cp\u003e133.4 ± 6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003eWeight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.565874730021598%\" valign=\"top\"\u003e\n \u003cp\u003e31.4 ± 7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.868250539956804%\" valign=\"top\"\u003e\n \u003cp\u003e30.7 ± 6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable.2 The distance\u0026nbsp;from the tube tip in the mandibular midline taped to the center of the lower lip.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.96018376722818%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.548238897396631%\" valign=\"top\"\u003e\n \u003cp\u003eRAE tube\u003c/p\u003e\n \u003cp\u003e(n=169)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.852986217457886%\" valign=\"top\"\u003e\n \u003cp\u003eWire-reinforced tracheal tube\u003c/p\u003e\n \u003cp\u003e(n=16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.638591117917304%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.96018376722818%\" valign=\"top\"\u003e\n \u003cp\u003eThe position of the middle lower lip (㎝)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.548238897396631%\" valign=\"top\"\u003e\n \u003cp\u003e17.9 ± 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.852986217457886%\" valign=\"top\"\u003e\n \u003cp\u003e18.9 ± 2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.638591117917304%\" valign=\"top\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"oral intubation, RAE tube, wire-reinforced tracheal tube, general anesthesia.","lastPublishedDoi":"10.21203/rs.3.rs-3789505/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3789505/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e Preformed oral tubes are preferred in clinical practice due to airway patency for enough operative fields during procedures. However, as the tube moves away from the carina during neck extension performed for procedures following intubation, the tracheal tube cuff may compress the vocal cords and potentially cause balloon-induced injury. In this study, we retrospectively investigated the incidence of tube replacement after procedures involving head and neck extension. We retrospectively investigated pediatric patients (6\u0026ndash;15 years) who underwent oral surgery. Intubation was performed using a cuffed 5.0\u0026ndash;7.5 mm ID RAE oral tube. Patients were subsequently positioned with a hyperextended neck for surgical procedures. The tube cuff position was reconfirmed by video laryngoscope, and the tube was replaced by a wire-reinforced tube. This retrospective study included 185 patients. We observed no intraoperative respiratory complications in this study. Among 186 patients, 16 (8%) underwent tube replacement owing to inaccurate cuff position after neck extension. Fixation of the lower lip in RAE tube was 17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 cm, which was not significantly different from values using wired-reinforced tracheal tubes 18.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 cm. We observed that inappropriate tube positioning after head and neck extension occurred in 16 patients (8%). Anesthesiologists should closely monitor and confirm the position of the tube cuff for safe airway management.\u003c/p\u003e","manuscriptTitle":"Risk of inappropriate fixation position for patients with cleft lip and palate after head and neck extension","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-12-29 06:51:48","doi":"10.21203/rs.3.rs-3789505/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1c74bf9d-935b-4435-88d6-c0cea791ff4d","owner":[],"postedDate":"December 29th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":27848708,"name":"Health sciences/Anatomy"},{"id":27848709,"name":"Health sciences/Medical research"},{"id":27848710,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2024-11-21T05:25:31+00:00","versionOfRecord":[],"versionCreatedAt":"2023-12-29 06:51:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3789505","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3789505","identity":"rs-3789505","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}