Migration of cut Foley catheter for posterior nasal packing into main bronchus

Summary Inadequate placement of Foley catheter for posterior nasal packing can cause upper airway obstruction, which is not noticed until tracheal extubation when the catheter is placed under general anesthesia. Here we present a 4-year-old girl who required nasopharyngeal packing with Foley catheter to control bleeding after adenoidectomy. Upon extubation, asphyxia developed and the catheter was emergently cut to deflate the balloon, then the distal portion of the catheter was found in the main bronchus. To avoid rare but hazardous complication, direct laryngoscopic inspection of the balloon is required just before tracheal extubation and intranasal Foley catheter should not be cut.