Inability to ventilate while using a silicone-based endotracheal tube

We present a complication associated with herniation of a specially designed silicone-based endotracheal tube (ETT) cuff used for laryngeal nerve monitoring (electromyographic [EMG] ETT). Lung ventilation in our patient was initially unimpeded. However, 30 minutes after initiation of anesthesia with desflurane and nitrous oxide, there was a sudden inability to ventilate due to the herniation of the ETT cuff presumably caused by diffusion of nitrous oxide into the silicone-based cuff. In vitro testing has shown that the increase in intracuff pressure during ventilation with nitrous oxide in the silicone-based EMG ETT is much greater (approximately 50 mmHg) than that in the polyvinyl chloride–based ETT (approximately 10 mmHg) routinely used in our department.