Oral Commissure Ulcer in an Extremely Preterm Infant: A Complication of Endotracheal Tube Fixation at Contralateral Oral Commissure During Lateral Positioning

Lip ulcers associated with endotracheal tube fixation are a known complication in adults, but their prevalence in neonates and preterm infants remains unclear. We report a case of a right oral commissure ulcer that developed during endotracheal tube fixation at the right oral commissure and left lateral decubitus positioning in an extremely preterm infant with unilateral pulmonary interstitial emphysema (PIE). A male infant was born at 24 weeks and four days of gestation, weighing 696 gm. He required mechanical ventilation for respiratory distress syndrome from birth. On day 66 of life, left lateral positioning and selective right main bronchial intubation were initiated to manage left-sided PIE. The endotracheal tube had initially been fixed at the center or left oral commissure, but on day 101 of life, it was switched to right oral commissure fixation. Eleven days later, an ulcer was observed at the right oral commissure. The ulcer was sutured under local anesthesia. The infant was extubated on day 122 of life and discharged on day 180 of life. The ulcer healed with minimal scarring. This case suggests that combining endotracheal tube fixation at the oral commissure with contralateral positioning may increase the risk of ulcer formation due to opposing forces from gravity and fixation, resulting in shear stress. Additionally, restricted positioning and continuous sedation may delay the early detection of ulcers. When using lateral positioning, we recommend avoiding contralateral oral commissure fixation of endotracheal tubes and securing the tube to the ipsilateral commissure or upper lip instead.