Introduction: Difficulties and complications associated with intubation are among the leading causes of surgery-related mortality in patients with obesity and obstructive sleep apnea. It is known that during perioperative intubations, the progression of the bougie may lead to serious injury and even rupturing in the trachea.
Case Report: A 46-year-old ASA II patient was assessed preoperatively for uvuloplasty. His body mass index was 34.7. Preparation was completed for the difficult intubation. The patient could not directly intubated with laryngoscopy but was intubated with bougie in the second trial. After the surgery 200 mg bridion was administered and the patient was extubated. He was then followed-up in PACU. Due to the stridor, it was thought that there was edema in his upper airway. At 45 minutes of PACU follow-up, it was noticed that upper airway edema regressed but there was subcutaneous emphysema giving a sense of rattle during palpation in the periphery of the right eye. It spread rapidly over the face. Afterwards he was intubated again through video laryngoscopy due to the risk of upper airway obstruction. Fiber optic examination and thorax tomography revealed that the fistula line was on the left lateral wall following cricoid cartilage. Mucosal damage of the patient healed spontaneously and weaning was conducted three days later in the ICU.
Conclusion: It was reported that tracheal injury and rupture occurs due to ’blind’ advancement of the bougie during intubation. Due to the identification of subcutaneous emphysema at 45 minutes during follow-up, it was thought that the bougie caused injury in the patient. The close long-term postoperative follow-up is important in cases where difficult intubation is conducted with bougie and intubation is achieved through multiple trials.

Keywords: Difficult intubation, Gum elastic bougie, Obstructive sleep apnea syndrome, Upper airway injury