Growing Pains: Unavoidable Collateral Damage or Time for a Warning?

Felipe Urdaneta, MD

To the Editor

There is no question that videolaryngoscopy (VL) has become one of the preferred methods for performing endotracheal intubation; its use has extended beyond perceived “difficult” patients, in the controlled setting of the OR, to use in the emergency department and also by paramedics in the field. The majority of the literature is positive, but as with other topics in medicine—especially when concepts or devices are relatively new—positive reports are reported more commonly than negative ones.

Recently I learned of a complication, a soft palate perforation during a routine, atraumatic, single attempt oral intubation requiring surgical repair, which occurred to one of my colleagues using a GlideScope. This prompted me to review the literature on the subject and much to my surprise I found several similar cases and descriptions of this complication, more commonly with the use of the GlideScope, but more recently with the McGrath VL as well.1-5 There are multiple potential predisposing factors to consider. Unfortunately, the sources are case reports, making assumptions or conclusions difficult. However, 2 factors stand out that I believe should be further scrutinized: 1) all cases involved the use of a stylet; its rigidity and angle of configuration vary (most reports claim that the tip of the stylet did not protrude beyond the tip of the ETT); and 2) when using indirect laryngoscopes such as VL (unlike when direct laryngoscopy is used), the user is looking at a screen rather than directly at tissue, and also the introduction of the tube is “blind” until the tip makes its appearance as it passes to the oropharynx. Therefore, during this journey, especially if there has been difficulty or multiple intubation attempts, it is possible for trauma to oropharyngeal structures to occur as the literature suggests.

Understanding that a Pandora’s Box is about to be opened, should we modify our practices and use these devices in a different manner? For example, only looking to the screen once we have directly watched the blade pass behind the tongue? Is this an indication of things to come and channeled devices provide some advantage in this regard? Should we look further into VL and stylet use, its shape, angle, and rigidity? Should a warning be sent stating there are cases of palatal damage with the use of these devices, or is this just due to growing pains, or collateral damage from the use of these novel devices and there is no reason to be concerned?

Felipe Urdaneta, MD
Gainesville, FL

Dr. Urdanetta has no financial relationship with any manufacturer of airway equipment or airway devices.


  1. Vincent RD Jr, Wimberly MP, Brockwell RC, Magnuson JS. Soft palate perforation during orotracheal intubation facilitated by the GlideScope videolaryngoscope. J Clin Anesth 2007;19:619-21.
  2. Williams D, Ball DR. Palatal perforation associated with McGrath videolaryngoscope. Anaesthesia 2009;64:1144-5.
  3. Cross P, Cytryn J, Cheng KK. Perforation of the soft palate using the GlideScope videolaryngoscope. Can J Anaesth 2007;54:588-9.
  4. Chin KJ, Arango MF, Paez AF, Turkstra TP. Palatal injury associated with the GlideScope. Anaesth Intensive Care 2007;35:449-50.
  5. Hsu WT, Hsu SC, Lee YL, Huang JS, Chen CL. Penetrating injury of the soft palate during GlideScope intubation. Anesth Analg 2007;104:1609-11.