[Endotracheal tube fire during laryngeal surgery: analysis of the root cause of a sentinel event].

Endotracheal tube fire during laryngeal surgery is a rare complication but one that has serious consequences. Surgeons, anesthesiologists and others involved with this type of surgery should become familiar with how to manage this difficult situation, which should be considered a sentinel event requiring prompt analysis of the root cause and surrounding circumstances. Measures to improve management should be implemented and training provided in order to prevent the recurrence of a similar unfortunate event. We report a case in which a patient's airway caught fire during use of an electrocautery device. The patient died as a result of the lesions sustained. We report the results of the investigation and the protocols for prevention and response implemented in our surgical department, in the hope that the experience will be of interest to others working in similar settings.