Successful fiberoptic intubation for a patient with lingual tonsillar hyperplasia

Hypertrophied lingual tonsils are rare, but may cause difficulty or inability in tracheal intubation during induction of general anesthesia. A 39-yr-old woman was scheduled for resection of symptomatic hypertrophied lingual tonsils. In this patient, we examined two methods of oro-tracheal intubation either with rigid laryngoscopy or flexible fiberoscopy using trans-nasal fiberopic monitoring. Direct laryngoscopy failed to expose the trachea because of large hypertrophied tissue, and fiberoscopic intubation was also difficult since a large mass hindered acquiring a suitable view. However, transnasal fiberoscopic monitoring could guide the orotracheal fiber into the trachea for intubation. When an anesthesiologist can predict the abnormality of lingual tonsils, this combination might be recommended for difficult airway and intubation.     

Orotracheal intubation with an AirWay Scope in a patient with Treacher Collins syndrome

Treacher Collins syndrome (TCS) is a congenital malformation of craniofacial development; in these patients conventional direct laryngoscopy is very difficult and often unsuccessful because of the upper airway malformation. A 20-year-old man with TCS was scheduled for elective tympanoplasty. The patient showed the characteristic facial appearance of TCS, and a difficult airway was anticipated. After careful anesthesia induction, direct laryngoscopy with Macintosh blade no. 4 of a direct laryngoscope failed to visualize the epiglottis, even with cricoid pressure, resulting in a grade 4 Cormack and Lehane view. Next, the AirWay Scope was easily inserted, and his glottic opening was clearly visualized. An 8.0-mm-internal-diameter tracheal tube was then advanced into the trachea without any difficulty. The AirWay Scope is a very useful airway device for orotracheal intubation; it provides an excellent view of the glottis without requiring alignment of the oral, pharyngeal, and laryngeal axes, and appears to be promising for use in patients with a difficult airway.     

Intubation in a patient with lingual tonsil hypertrophy using an intubating laryngeal mask airway in combination with fiberoptic intubation

A 66-yr-old man was scheduled for colon resection under general anesthesia. There were no findings suggesting difficulty of airway management. After induction of anesthesia, manual ventilation via a facemask was suboptimal, but increased fresh gas flow improved it. At direct laryngoscopy after achieving muscular relaxation, the arytenoids and epiglottis could not be seen even by an expert anesthesiologist. Intubating laryngeal mask airway (ILMA) was inserted to patient's larynx and ventilation could be continued. Tracheal intubation through ILMA was impossible because of hard resistance for inserting the endotracheal tube. Fiberoptic bronchoscopy revealed that the hypertrophied lingual tonsil obstructed the aperture of ILMA. Several attempts were made for intubation using fiberoptic tracheal intubation technique through ILMA and finally the patient's trachea was intubated without any bleeding or swelling of laryngeal tissues. The effectiveness of ILMA for the patient with lingual tonsil hypertrophy is still unknown, but the insertion of ILMA might be considered for safe airway management in combination with a fiberscope.     

Tracheal intubation for two patients with lingual tonsil hyperplasia and prospect of difficult airway management

Lingual tonsil hyperplasia is rare, but may cause difficult or inpossible tracheal intubation. We experienced two cases of tracheal intubation for lingual tonsil hyperplasia. A 71-yr-old man was scheduled for resection and biopsy of symptomatic hypertrophied lingual tonsils. In this patient, we performed oro-tracheal intubation by rigid laryngoscopy from left oral angle, because left hypertrophied lingual tonsils are smaller than those on the right side. A 44-yr-old man was scheduled for resection of symptomatic hypertrophied lingual tonsils after lingual tonsillitis. In this patient, we performed nasotracheal intubation using fiberoptic bronchoscopy with assist of jaw-lift and tongue-extension. When an anesthesiologist can predict the abnormality of lingual tonsils, these methods might be recommended for difficult airway and intubation. However, it is necessary to prepare a difficult airway management set including laryngeal mask airway, intubating laryngeal mask airway, fiberoptic bronchos-copy and transcutaneous tracheotomy set. And most important is preliminary evaluation of airway and cautious planning of tracheal intubation.     

Airway management in obese patients

The well-known difficulties in airway management in obese patients are caused by obesity-related airways and respiratory changes. Anesthesiologists confront a number of troubles, including rapid oxygen desaturation, difficulty with laryngoscopy/intubation and mask ventilation, and increased susceptibility to the respiratory depressant effects of anesthetic drugs. Preoperative assessment of the airways in the obese should include examination of specific predictors of difficult mask ventilation other than those for difficult intubation. Difficulties in airway management are decreased after providing optimal preoxygenation and positioning (“ramped”). Other strategies may include availability of alternative airway management devices, including new video laryngoscopes that significantly improve the visualization of the larynx and thereby facilitate intubation. If awake intubation is mandatory, it may be performed with fibrobronchoscope after providing an adequate topical anesthesia and sedation with short-acting drugs, such as remifentanil. Succinylcholine for rapid sequence induction might be replaced by rocuronium where sugammadex is available for reversal. A complete reversal of neuromuscular block, measured by train-of-four monitoring, should be obtained before extubation, which requires a fully awake patient in the same position with airway equipment used for intubation.     

A case of difficult airway due to lingual tonsillar hypertrophy in a patient with Down's syndrome

In this report, we describe airway management of symptomatic lingual tonsillar hypertrophy in a pediatric patient with Down's syndrome. Besides obstructive sleep apnea, the history included a small atrial septal defect with mild aortic regurgitation and Moyamoya disease. Anesthesia was induced with IV administration of 1 mg/kg of propofol, followed by inhalation of sevoflurane in 100% oxygen. Muscle relaxants were not used on induction. Rigid laryngoscopy could not visualize the epiglottis because of hypertrophied tonsillar tissue, and mask ventilation became difficult when spontaneous breathing stopped. We avoided using a laryngeal mask airway because of a slight bleeding tendency presumably caused by preoperative antiplatelet therapy. Fiberoptic bronchoscopy through the nasal cavity in combination with jet ventilation successfully identified the glottis and allowed nasotracheal intubation to be accomplished. After lingual tonsillectomy, the patient was extubated on the seventh postoperative day, after supraglottic edema had resolved. Fiberoptic nasotracheal intubation under inhaled anesthesia may therefore be preferable in pediatric or uncooperative patients with symptomatic lingual tonsillar hypertrophy.     

Fentanyl attenuates the hemodynamic response to endotracheal intubation more than the response to laryngoscopy

We examined the effectiveness of avoiding laryngoscopy in reducing the hemodynamic responses to orotracheal intubation during the induction of anesthesia. One hundred surgical patients who required orotracheal intubation were randomly allocated into four groups. The first and third groups underwent fiberoptic intubation, in which an anesthesiologist inserted the endotracheal tube into the trachea under TV monitoring through a bronchoscope, and the second and fourth groups underwent conventional orotracheal intubation using a rigid laryngoscope. The third and fourth groups were pretreated with 2 microg/kg fentanyl IV immediately before the induction of anesthesia. Blood pressure and heart rate were measured noninvasively. A significant reduction in hemodynamic response was seen in only the group treated with fentanyl and intubated using the fiberoptic technique. Without fentanyl, there was no significant difference in hemodynamic changes between the groups. We conclude that the administration of fentanyl suppresses the hemodynamic responses to endotracheal intubation more than it does to laryngoscopy. There was no significant difference in the hemodynamic responses to orotracheal intubation by fiberscopy and laryngoscopy without fentanyl pretreatment, whereas 2 microg/kg fentanyl significantly reduced the hemodynamic responses in the group intubated by fiberscopy. IMPLICATIONS: We assessed the effectiveness of avoiding laryngoscopy for orotracheal intubation. There was no significant difference in the hemodynamic responses to orotracheal intubation by fiberscopy and laryngoscopy without fentanyl pretreatment, whereas 2 microg/kg fentanyl significantly reduced the hemodynamic responses in the group intubated by fiberscopy. Pretreatment of fentanyl and fiberoptic intubation might be recommended for avoiding hyperdynamic responses.     

Use of a new videolaryngoscope (GlideScope®) in the management of a difficult airway

PURPOSE: To describe the clinical use of a new videolaryngoscope in a patient who had repeatedly been difficult or impossible to intubate by conventional direct laryngoscopy. This device provided excellent glottic visualization and permitted easy endotracheal intubation. CLINICAL FEATURES: A 74-yr-old male presenting for repeat elective surgery had a history of failed intubations by direct laryngoscopy and pulmonary aspiration with a laryngeal mask airway. He refused awake flexible fibreoptic intubation. After the induction of general anesthesia, laryngoscopy was performed using a GlideScope. This provided complete glottic exposure and easy endotracheal intubation. CONCLUSION: This new videolaryngoscope provided excellent laryngeal exposure in a patient whom multiple experienced anesthesiologists had repeatedly found to be difficult or impossible to intubate using direct laryngoscopy. The clinical role of this device awaits confirmation in a large series of difficult airways.     

Asymptomatic vallecular cyst: airway management considerations

Airway problems are easiest to manage when they are anticipated. Difficult intubation might, however, occur in patients with no obvious signs or symptoms suggesting airway difficulty. We describe a case where laryngeal inlet was obscured by a large vallecular cyst that was discovered during rapid-sequence induction of general anesthesia, causing difficulty in tracheal intubation. Once the patient was allowed to recover from general anesthesia, the trachea could be safely intubated using a fiberoptic bronchoscope.     

Canadian pediatric anesthesiologists prefer inhalational anesthesia to manage difficult airways: A survey

PURPOSE: To survey Canadian pediatric anesthesiologists to assess practice patterns in managing pediatric patients with difficult airways. METHODS: Canadian pediatric anesthesiologists were invited to complete a web survey. Respondents selected their preferred anesthetic and airway management techniques in six clinical scenarios. The clinical scenarios involved airway management for cases where the difficulty was in visualizing the airway, sharing the airway and accessing a compromised airway. RESULTS: General inhalational anesthesia with spontaneous respiration was the preferred technique for managing difficult intubation especially in infants (90%) and younger children (97%), however, iv anesthesia was chosen for the management of the shared airway in the older child (51%) where there was little concern regarding difficulty of intubation. Most respondents would initially attempt direct laryngoscopy for the two scenarios of anticipated difficult airway (73% and 98%). The laryngeal mask airway is commonly used to guide fibreoptic endoscopy. The potential for complete airway obstruction would encourage respondents to employ a rigid bronchoscope as an alternate technique (17% and 44%). CONCLUSION: Inhalational anesthesia remains the preferred technique for management of the difficult pediatric airway amongst Canadian pediatric anesthesiologists. Intravenous techniques are relatively more commonly chosen in cases where there is a shared airway but little concern regarding difficulty of intubation. In cases of anticipated difficult intubation, direct laryngoscopy remains the technique of choice and fibreoptic laryngoscopy makes a good alternate technique. The use of the laryngeal mask airway was preferred to facilitate fibreoptic intubation.     

Submucous fibrosis secondary to chewing of quids: Another cause of unanticipated difficult intubation

PURPOSE: To report a case of unusual difficult intubation secondary to oral submucosal fibrosis (SMF) associated with malignancy of the hypopharynx. CLINICAL FEATURES: A 57-yr-old male, ASA-I physical status presented for percutaneous nephrolithotripsy. The patient was a known alcoholic and smoker with a habit of chewing quids for the past 36 years. Airway assessment revealed oral SMF and slight difficulty in opening the mouth fully. Mentohyoid and mentothyroid distances were normal. However, during intubation, unanticipated difficulty was encountered. On direct laryngoscopy, the tip of the epiglottis could barely be visualized. Intubation was possible after passing a gum elastic bougie blindly under the epiglottis and negotiating a 7.0 internal diameter tracheal tube over it. Postoperatively, indirect laryngoscopy (IDL) showed severe SMF involving the oral cavity, epiglottis and pyriform fossae and an ulcerative malignancy of the hypopharynx with fixation of the left hemilarynx. CONCLUSION: SMF is a premalignant condition of the oral cavity associated with fibrosis of involved structures that can be associated with malignancy of the aerodigestive tract. Distortion of the airway anatomy may render intubation difficult. IDL maybe useful in the preoperative evaluation of these patients.     

The difficult airway with recommendations for management – Part 2 – The anticipated difficult airway

Background

Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway.

Methods

To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned.

Principal findings

Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician’s experience, must also be considered in deciding the appropriate strategy.

Conclusions

With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.     

Pentax AWS airway scope

Pentax AWS Airway Scope (Pentax, Japan) is a new videolaryngoscope. We successfully used the device in 15 patients and in other two patients with difficult airways. In a 51-year-old woman, after induction of anesthesia and neuromuscular blockade, laryngoscopy using a Macintosh blade showed only the tip of the epiglottis and tracheal intubation failed. Pressure on the neck and the use of gum elastic bougie did not solve the problem. When the Airway Scope was used, a full view of the glottis was obtained and the trachea was easily intubated. In a 71-year-old man, after induction of anesthesia and neuromuscular blockade, facemask ventilation was moderately difficult. At laryngoscopy using a Macintosh blade, the epiglottis was long and tubular, and tracheal intubation failed. With the Airway Scope, the trachea was intubated easily. We believe that the Pentax AWS videolaryngoscope is useful in patients with and without difficult airways.     

Hypertrophy of the lingual tonsil and difficulty in airway control. A clinical case]

A male patient suffering for exertional angina was scheduled for coronary bypass. Physical examination was unremarkable except for oropharynx classified as Mallampati II. After anesthetic induction with fentanyl 10 micrograms/kg, thiopental 5 mg/kg and muscle relaxation with succynilcoline 1 mg/kg, the patient was ventilated via a face mask. Laryngoscopy revealed a bulky mass arising from the rigth base of the tongue hiding the epiglottis and all the vocal apparatus (Cormack class 4); a failed intubation caused bleeding. Facial mask ventilation became more difficult therefore, considering the task on managing the airway, a n. 4 laryngeal mask was positioned by the senior anesthetist. Two intubation attempts failed while ventilation via laryngeal mask became more and more difficult. Surgery was therefore cancelled due to inability to airway management. The mass, biopsied by an otolaryngologist, resulted to be a lingual tonsillar hyperthrophy and therefore was not removed. The patients was re-scheduled for cardiac surgery. Maintaining spontaneous breathing during light sedation, with topical anesthesia, this patient was successfully intubated over an Olympus BF P 10 bronchoscope. The patient had an uneventful operation, was regularly extubated and was discharged on the sixth postoperative day free from airway complications. Although we followed only some of the guidelines for the management of the difficult airway: a senior anesthetist was immediately called when an anatomic alteration was evident; progressive difficulty in maintaining the airway prompted the positioning of a LMA, the restoration of the spontaneous breathing and the cancellation of the elective operation had been mandatory when a class 4 Cormack was found at laryngoscopy. This situation requires an alternative approach to intubation or with the retrograde technique or with the aid of a fiberscope both maintaining spontaneous breathing.     

Airway access using an endotracheal tube changer for safe extubation in an infant with a difficult airway

We present a case where airway access was maintained using an endotracheal tube changer (ETC) after extubation in an infant with a difficult airway. A 4-month-old male infant with bilateral cleft lip and palate, micrognathia, schizencephaly, undescended testis, and abnormality of chromosomes 10 was scheduled for bilateral cleft lip repair. After anesthesia induction with thiamylal and vecuronium, we found that laryngoscopy was difficult (Cormack and Lehane grade III) despite external laryngeal compression. Since there was no fiberoptic bronchoscopy for an infant in our department, and the fact that epiglottis could be visualized with external laryngeal compression, three anesthesiologists attempted tracheal intubation in turn and intubation was successful at last. The surgery was concluded uneventfully; but since endotracheal intubation had been difficult, special care was taken for extubation. We used an ETC for tracheal tube passing into the endotracheal tube at the time of extubation. Although using the ETC in infant with difficult airway for extubation remains controversial, we believe that for a difficult airway, even in an infant, a flexible ETC is a useful device for temporal airway access after extubation.     

Airway management of a patient with Forestier's disease

Forestier's disease, also called diffuse idiopathic skeletal hyperostosis (DISH), is a noninflammatory enthesopathy, ossifying the anterolateral spine and sparing the disc and joint space in elderly men, mostly at thoracic levels. Intubation difficulty and spinal cord injury are potential problems when managing the airway in DISH patients. We report a patient with Forestier's disease who was admitted for osteophyte resection. After taking a detailed history, we evaluated the airway carefully. Also, preparation for difficult intubation was done. After a rapid sequence induction, we performed mask ventilation and laryngoscopy without hyperextension of the neck, to prevent spinal cord injury. Although the worldwide standard for management of the airway in DISH patients is awake fiberoptic intubation, we chose conventional laryngoscopy because a fiberoptic bronchoscope was not available.     

Management of airway in patients with laryngeal tumors

STUDY OBJECTIVE: To describe our systematic approach to securing the airway in patients with laryngeal tumors, developed over a 10-year period. DESIGN: Retrospective analysis. SETTING: University-affiliated veterans administration medical center. PATIENTS: Eight hundred one patients presenting for laryngeal tumor surgery in a 10-year period, 285 of whom underwent tracheostomy (25 with local anesthesia and 260 with general anesthesia). INTERVENTIONS: Preoperative examination, including history, physical examination, computed axial tomography and/or magnetic resonance imaging, and ear, nose, and throat surgeons' evaluation via indirect laryngoscopy or fiberoptic bronchoscopy were performed before the anesthesiologist's interventions. Local (topical) anesthesia and mild sedation were used for laryngeal evaluation with fiberoptic bronchoscopy. Tumor grade was then established, which determined how the airway would be secured: general anesthesia induction, receive topical anesthesia for awake, direct laryngoscopy, and tracheal intubation, or undergo tracheostomy with local anesthesia. MEASUREMENTS AND MAIN RESULTS: When the airway was secured, surgeons performed the biopsy, (any) tumor debulking, laser excision, or tracheostomy to establish both the airway and the diagnosis. Pulmonary function, including flow-volume loops and blood gas analysis were also useful in evaluating the degree of obstruction and gas exchange. In the event of respiratory distress, tracheostomy was performed after tracheal intubation or with local anesthesia, followed by direct laryngoscopy and biopsy. Depending on the diagnosis, further surgery and radiation treatment were planned next. CONCLUSIONS: With these guidelines, we have reduced the frequency of emergencies because of a lost airway, bleeding, or dislodging of tumor.     

The intubating laryngeal mask airway in failed fibreoptic intubation

PURPOSE: Prediction of difficult tracheal intubation is not always reliable and management with fibreoptic intubation is not always successful. We describe two cases in which blind intubation through the intubating laryngeal mask airway (ILMA FasTrach) succeeded after fibreoptic intubation failed. CLINICAL FEATURES: The first patient, a 50 yr old man, was scheduled for elective craniotomy for intracerebral tumour. Difficulty with intubation was not anticipated. Manual ventilation was easily performed following induction of general anesthesia, but direct laryngoscopy revealed only the tip of the epiglottis. Intubation attempts with a styletted 8.0 mm endotracheal tube and with the fibreoptic bronchoscope were unsuccessful. A #5 FasTrach was inserted through which a flexible armored cuffed 8.0 mm silicone tube passed into the trachea at the first attempt. The second patient, a 43 yr old man, presented with limited mouth opening, swelling of the right submandibular gland that extended into the retropharynx and tracheal deviation to the left. He was scheduled for urgent tracheostomy. Attempted awake fibreoptic orotracheal intubation under topical anesthesia showed gross swelling of the pharyngeal tissues and only fleeting views of the vocal cords. A #4 FasTrach was easily inserted, a clear airway obtained and a cuffed 8.0 mm silicone tube passed into the trachea at the first attempt. CONCLUSION: The FasTrach may facilitate blind tracheal intubation when fibreoptic intubation is unsuccessful.     

Subcutaneous emphysema and pneumomediastinum after translaryngeal intubation: tracheal perforation due to unsuccessful fiberoptic tracheal intubation

A 77-year-old man was scheduled to undergo a cervical lymph node biopsy under general anesthesia. Although awake, nasotracheal fiberoptic intubation was initially planned because of an anticipated difficult airway, the attempt was unsuccessful. Orotracheal intubation was subsequently performed under direct laryngoscopy without difficulty. After initiating positive pressure mechanical ventilation, subcutaneous and mediastinal emphysema developed. The cause of this emphysema was considered to be tracheal perforation after an unsuccessful attempt at fiberoptic tracheal intubation.     

Anesthesia induction for a difficult intubation infant with a laryngeal cyst

We report a case of difficult airway in a 37-day-old female with a laryngeal cyst during induction of general anesthesia. This case illustrates that upper airway obstruction can occur during induction of anesthesia with an unusual infantile aryepiglottic fold cyst. In this case, successful orotracheal intubation was achieved with spontaneous respiration, and preoperative information on orientation of the lesion assisted in positioning the patient to minimize the degree of dynamic obstruction.