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Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 38-39

Fishing for a needle in a haystack! retained swivel knife in the adenoids of patient posted for endoscopic septoplasty with inferior turbinate reduction

1 Department of Anesthesiology and Critical Care, Valluvanad Hospital Complex, Palakkad, Kerala, India
2 Department of Otolaryngology, Valluvanad Hospital Complex, Palakkad, Kerala, India

Date of Submission28-Oct-2022
Date of Acceptance02-Feb-2023
Date of Web Publication20-Apr-2023

Correspondence Address:
Dr. Anirudh Elayat
Department of Anaesthesiology and Critical Care, Valluvanad Hospital Complex Limited, Kanniyampuram, Ottapalam, Palakkad - 679 104, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_42_22

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How to cite this article:
Elayat A, Chandran V. Fishing for a needle in a haystack! retained swivel knife in the adenoids of patient posted for endoscopic septoplasty with inferior turbinate reduction. Airway 2023;6:38-9

How to cite this URL:
Elayat A, Chandran V. Fishing for a needle in a haystack! retained swivel knife in the adenoids of patient posted for endoscopic septoplasty with inferior turbinate reduction. Airway [serial online] 2023 [cited 2023 Jun 7];6:38-9. Available from: https://www.arwy.org/text.asp?2023/6/1/38/374367

Listed as one among the 27 'never events' in National quality forum in the United States, retained sponges and instruments are catastrophic yet underreported events due to heavy penalty levied with respect to medicolegal and compensation charges.[1]

A 19-year-old male patient weighing 60 kg was admitted with complaints of repeated upper respiratory tract infection and sleep apnoea for past 4 months. He was diagnosed with deviated nasal septum with septal spur and was posted for endoscopic septoplasty and inferior turbinate reduction surgery. The trachea was intubated using 8.0 cuffed endotracheal tube after induction of anaesthesia and a throat pack was placed immediately following intubation. To facilitate access and resection, the cartilaginous portion of nasal septum was excised using 5.5 mm Ballenger swivel knife. Upon conclusion, the surgeon noticed that the tip of the swivel knife kept on the instrument trolley was missing [Figure 1]. The suspected site of dislodgement was the mucosal pocket created by the swivel knife, but after detailed examination for 20 min, the 5.5-mm blade tip was retrieved using Blakesley forceps from within the hypertrophied crypts of adenoid tissue [Figure 2]. Haemostasis was ensured and after thorough suctioning of the oral cavity, throat pack was removed and patient was extubated smoothly on table.
Figure 1: Ballenger swivel knife with circled area showing missing blade

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Figure 2: Retrieved knife blade from the adenoid tissue

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The knife is constructed so as to allow the blade to orient its cutting edge along the direction in which the prong tips are moving, making it efficient in septal reconstruction as well as removing occasional septal spurs that hinder access for nasal endoscopic surgery.[2] In retrospect, it seems most likely to have broken in the nasal cavity which had later lodged in to adenoid tissue.

This case is interesting for raising relevant issues regarding patient complications and safety, namely: (1) Clinical reports of a broken blade in the nasopharynx are rare and no protocols are currently in place to prevent its occurrence globally.[3] (2) The hypertrophied adenoids acted as the first-line barrier-based defence mechanisms without which, the blade would have migrated further down and extremely difficult to locate. (3) Although cuffed endotracheal tube and throat pack certainly increased the margin of safety, if it had not been for good clinical acumen on the part of surgeon to notice the missing blade tip, the patient might have been extubated with the blade still lodged in the adenoids, causing bleeding or aspiration in the post-anaesthesia care unit.

Currently, the universally followed protocol, centred around maintaining proper counts is not foolproof as it does not account for retained bits or part of instruments.[4] Our experience with this case highlights the limitations of currently practiced protocols for prevention of such events. However, a few changes can be brought into clinical practice including: (1) Switching over to newer technology including bipolar radio frequency plasma-mediated ablation of cartilage. (2) Using multiple fixed blades without hinges. (3) Using small neurosurgical patties soaked in adrenaline as a method for decongestion. (4) A dedicated committee for quality control and assessment of performance of surgical equipment to reduce instrument malfunction or breakage.[5] (5) An additional checklist point on the condition of instruments before closure. (6) Lastly, pertaining to our case, a high index of suspicion should be maintained and nasopharynx and adenoids should always be inspected as potential sites for hidden foreign objects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

National Quality Forum. Serious Reportable Events in Healthcare – 2011 Update. Washington, DC: NQF; 2011.  Back to cited text no. 1
Ballenger WL. XXIV. The submucous resection of the nasal septum. A new technic with the author's Swivel Knife, reducing the average time of the operation several minutes. Ann Otol Rhinol Laryngol 1905;14:394-416.  Back to cited text no. 2
Ray L, Chatterjee P, Bandyopadhyay SN, Das S, Sinha R, Nandy TK. An unusual foreign body (Big Metallic Nut) in the nasopharynx of an infant. Indian J Otolaryngol Head Neck Surg 2004;56:309-10.  Back to cited text no. 3
Jotdar A, Dutta M, Mukhopadhyay S. Nasal foreign body, dislodged and lost – Can the adenoids help? J Clin Diagn Res 2015;9:MD06-7.  Back to cited text no. 4
Recommended practices for sponge, sharp, and instrument counts. AORN Recommended Practices Committee. Association of periOperative Registered Nurses. AORN J 1999;70:1083-9.  Back to cited text no. 5


  [Figure 1], [Figure 2]


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