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• ‘Better safe than sorry’
  Stijn Bekkers, Johannes Adriaan Rijken
  Published on: 26 February 2021

• Published on: 26 February 2021

  ‘Better safe than sorry’

  • Stijn Bekkers, Resident Otolaryngology—Head and Neck Surgery Radboud University Medical Center
  • Other Contributors:
    • Johannes Adriaan Rijken, Otolaryngologist & Head and Neck surgeon

  With great interest we have read the study by Deshayes et al. The authors present two cases of silvernitrate (AgNO3) aspiration in laryngectomized patients.
  1) In both cases the applicator tip broke off.
  2) The authors conclude that treatment should comprise oral antibiotics and one should refrain from bronchial washing with sodium chloride solution.
  With this response we would like to reply to both points addressed above.
  1.
  Five years ago we were confronted with the aspiration of an AgNO3 applicator tip in a laryngectomized patient. After the incident we analyzed the case to prevent future AgNO3 applicator tip aspiration. The AgNO3 pencil, used in both our case and the cases in the current article, is specifically designed to treat dermal lesions like verruca which requires repeated use. The pencil therefore contains a relatively large volume of AgNO3. AgNO3 is a brittle substance. When the pencil is used with a little too much pressure there is risk for the tip to break, and when used in a tracheostomy, there is risk for aspiration.
  Our case led us to immediately stop using the AgNO3 pencils for treatment of granulation tissue in a tracheostomy. We strongly recommend the use of disposable AgNO3 cutaneous sticks for the treatment of granulation tissue around a tracheostomy. The disposable sticks contains less volume of AgNO3. Moreover, the stick is easier to use in narrow spaces like a tracheostomy.
  2.
  Aspiration of AgNO3 i...

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  With great interest we have read the study by Deshayes et al. The authors present two cases of silvernitrate (AgNO3) aspiration in laryngectomized patients.
  1) In both cases the applicator tip broke off.
  2) The authors conclude that treatment should comprise oral antibiotics and one should refrain from bronchial washing with sodium chloride solution.
  With this response we would like to reply to both points addressed above.
  1.
  Five years ago we were confronted with the aspiration of an AgNO3 applicator tip in a laryngectomized patient. After the incident we analyzed the case to prevent future AgNO3 applicator tip aspiration. The AgNO3 pencil, used in both our case and the cases in the current article, is specifically designed to treat dermal lesions like verruca which requires repeated use. The pencil therefore contains a relatively large volume of AgNO3. AgNO3 is a brittle substance. When the pencil is used with a little too much pressure there is risk for the tip to break, and when used in a tracheostomy, there is risk for aspiration.
  Our case led us to immediately stop using the AgNO3 pencils for treatment of granulation tissue in a tracheostomy. We strongly recommend the use of disposable AgNO3 cutaneous sticks for the treatment of granulation tissue around a tracheostomy. The disposable sticks contains less volume of AgNO3. Moreover, the stick is easier to use in narrow spaces like a tracheostomy.
  2.
  Aspiration of AgNO3 is rare, so there is no clinical evidence that proves for or against bronchial washing with sodium chloride solution. From a theoretical perspective there is an argument to advise bronchial washing with sodium chloride solution after AgNO3 aspiration. As previously concluded, AgNO3 is activated when it is dissolved in water. AgNO3 is neutralized when in contact with sodium chloride solution (AgNO3 → AgCl + NaNO3). Correspondingly, the manufacturer advices to repeatedly wash the stomach with sodium chloride solution after AgNO3 ingestion. The authors conclude that one should not wash with sodium chloride solution due to the risk for spread of AgNO3 and potential secondary stenosis. Corresponding to the manufacturer information AgNO3 is neutralized when dissolved in sodium chloride solution. Based on theory and manufacturer information we advise thorough bronchial washing with sodium chloride solution after AgNO3 aspiration.

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  Conflict of Interest:
  None declared.

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