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.     

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.     

Difficult tracheal intubation in a patient suspected of malignant hyperthermia

We report anesthetic management of a patient suspected of malignant hyperthermia with difficult tracheal intubation. A 64-year-old man was scheduled for a fixation of humerus bone fractures in prone position. He had a history of difficult tracheal intubation due to masseter spasm, and his niece was suspected to be malignant hyperthermia. Anesthesia was induced with propofol using a target controlled infusion. No muscle relaxant was given and spontaneous breathing was maintained. Trials for tracheal intubation failed whenever using a standard laryngoscope, a bronchofiberscope, a laryngeal mask airway or an intubating laryngeal mask airway. Resecting the epiglottic elevating bar of an intubating laryngeal mask airway enabled fiberoptic tracheal intubation. No symptom suggesting malignant hyperthermia developed.     

Difficult airway management due to obesity and lingual tonsillar hyperplasia

We experienced anesthesia for a female patient of BMI 39.2 with unanticipated lingual tonsillar hyperplasia. At the induction of anesthesia, both mask ventilation and tracheal intubation were difficult due to the lingual tonsillar hyperplasia. However, tracheal intubation was performed by Intubating LMA with the fiberoptic bronchoscopy. After the placing of TE (the catheter for tracheal tube exchanger), the tracheal tube was extubated without any airway trouble. Following the extubation, the opening of the respiratory tract was evaluated by TE and the fiberoptic bronchoscopy. In this case we confirmed that the ASA difficult airway algorithm was also useful in the presence of lingual tonsillar hyperplasia.     

Failed tracheal intubation using a laryngoscope and intubating laryngeal mask

PURPOSE: To report unexpected failed tracheal intubation using a laryngoscope and an intubating laryngeal mask, and difficult ventilation via a facemask, laryngeal mask and intubating laryngeal mask, in a patient with an unrecognized lingual tonsillar hypertrophy. CLINICAL FEATURES: A 63-yr-old woman, who had undergone clipping of an aneurysm seven weeks previously, was scheduled for ventriculo-peritoneal shunt. At the previous surgery, there had been no difficulty in ventilation or in tracheal intubation. Her trachea remained intubated nasally for 11 days after surgery. Preoperatively, her consciousness was impaired. There were no restrictions in head and neck movements or mouth opening. The thyromental distance was 7 cm. After induction of anesthesia, manual ventilation via a facemask with a Guedel airway was suboptimal and the chest expanded insufficiently. At laryngoscopy using a Macintosh or McCoy device, only the tip of the epiglottis, but not the glottis, could be seen, and tracheal intubation failed. There was a partial obstruction during manual ventilation through either the intubating laryngeal mask or conventional laryngeal mask; intubation through each device failed. Digital examination of the pharynx, after removal of the laryngeal mask, indicated a mass occupying the vallecula. Lingual tonsillar hypertrophy (1 x 1 x 2 cm) was found to be the cause of the failure. Awake fibrescope-aided tracheal intubation was accomplished. CONCLUSIONS: Unexpected lingual tonsillar hypertrophy can cause both ventilation and tracheal intubation difficult, and neither the laryngeal mask nor intubating laryngeal mask may be helpful in the circumstances.     

Differential lung ventilation using laryngeal mask airway and a bronchial blocker tube for a patient with unanticipated difficult intubation

We experienced differential lung ventilation using laryngeal mask airway (LMA) and a bronchial blocker tube for a patient with unanticipated difficult intubation. A 27-year-old man was diagnosed as the left spontaneous pneumothorax and scheduled for bulla excision with video-assisted thoracic surgery. Because of failure in tracheal intubation of the usual double lumen tube, we inserted LMAProseal #4 and accomplished differential lung ventilation using a bronchial blocker tube through LMA. This method will be effective in differential lung ventilation of the patient with difficult airway.     

Complicated airway due to unexpected lingual tonsil hypertrophy

We report an unexpected failed laryngeal mask airway in a patient with unrecognized lingual tonsil hypertrophy (LTH). A 19-year-old obese woman presented for extraction of multiple teeth via intravenous general anesthesia. Surgery was interrupted due to a laryngospasm midway through the procedure. The laryngospasm required the existing laryngeal mask airway to be removed so the patient could be suctioned. Although it is unclear the extent of obstruction caused by LTH, the surgery had to be postponed due to the discovery of enlarged lingual tonsils, which prevented endotracheal intubation. One reason for unexpected difficult airways is attributed to LTH. It is recognized that LTH is more common in patients with obstructive sleep apnea; however, LTH also has an increased prevalence in obese children with prior palatine tonsillectomies or adenoidectomies. Unexpected LTH can complicate general anesthesia by making placement of a laryngeal mask airway difficult. Thus, further research needs to be conducted to gain a deeper understanding on how to reduce the risks presented by LTH during sedation surgeries.     

Intubação traqueal difícil com fibra óptica em bebê de um mês de idade com síndrome de Treacher Collins

Neonates and small infants with craniofacial malformation may be very difficult or impossible to mask ventilate or intubate. We would like to report the fiberoptic intubation of a small infant with Treacher Collins Syndrome using the technique described by Ellis et al.

Airway management of a patient with tracheal stenosis for surgery in the prone position

PURPOSE: When tracheal intubation is required in a patient with an uncollapsible tracheal stenosis, the tip of the tube is usually positioned proximal to the stenosis. Only the tip of the tube may be in the trachea and the tube can be dislodged. We report the successful airway management of a patient with an uncollapsible tracheal stenosis who underwent cranial surgery in the prone position. CLINICAL FEATURES: A 49-yr-old man with the saber-sheath trachea (stenosis of the entire intrathoracic trachea) was scheduled for a posterior fossa surgery for resection of a cerebellar tumour. Anesthesia was induced by allowing the patient to inhale spontaneously oxygen and increasing concentrations of sevoflurane up to 5%, without airway obstruction. After injection of vecuronium, an airway exchange catheter was inserted orally into the trachea. A laryngeal mask airway was then inserted with the exchange catheter in place and, with the aid of a fibrescope, a 6.0-mm reinforced tracheal tube was passed through the laryngeal mask into the trachea so that the tip of the tube was about 1 cm proximal to the stenosis. The patient was turned to the prone position and the operation proceeded uneventfully. CONCLUSIONS: The laryngeal mask and an airway exchange catheter were used as backups to tracheal intubation in this patient with tracheal stenosis in the prone position. Should the trachea be extubated accidentally, it may be re-intubated through the laryngeal mask and ventilation may be possible through the laryngeal mask or the exchange catheter.     

Tracheostomy,lingular tonsillectomy and sleep-related breathing disorders

Laser resection of lingual tonsils and formal closure of a tracheostomyimproved the airway in a 14-yr-old patient with Down’ssyndrome. Non-invasive airway support to treat obstructive sleepapnoea was postponed with this treatment. During the anaesthetica laryngeal mask airway was used to support the airway afterlingual tonsillectomy, to assess the suitability of de-functioningthe tracheostomy. Laryngeal mask airways assist management oflingual tonsils. Lingual tonsillar hypertrophy can lead to obstructivesleep disorders. Br J Anaesth 2002; 88: 724–6     

Tracheal bleeding during awake fiberoptic intubation

Fiberoptic intubation can cause laryngeal injury during blind insertion of a tracheal tube. A patient with hypopharyngeal cancer was scheduled for laser surgery and we selected nasal fiberoptic intubation due to laryngeal deformity. Just after insertion of a tracheal tube, tracheal bleeding occurred and ventilation because difficult. Emergency tracheostomy was required to restore adequate oxygenation. A piece of mucosa and blood clot was found in the lumen of the tracheal tube and hematoma was observed on the surface of arytenoid cartilage. Careful selection and optimal manipulation of the tracheal tube is important and surgical airway access should be immediately available before fiberoptic procedure in a patient with friable and vascular-rich laryngeal lesion.     

The new air-QTM intubating laryngeal airway for tracheal intubation in children with anticipated difficult airway: a case series

The air-Q intubating laryngeal airway (ILA) is a new supraglottic airway device which may overcome some limitations inherent to the classic laryngeal mask airway for tracheal intubation. We present a case series of patients with anticipated difficult airway in whom the air-Q ILA was successfully used as a conduit for fiberoptic intubation.     

Awake tracheal intubation through the laryngeal mask in neonates with upper airway obstruction

Neonates with Pierre Robin or Treacher-Collins syndrome are at risk of upper airway obstruction and may require surgical fixation of the tongue to the mandible. Such neonates are at high risk of hypoxia during induction of anesthesia and thus awake fiberoptic intubation would be required. We experienced neonates in whom awake fiberoptic intubation could not be carried out, because of severe hypoxia. Awake insertion of the laryngeal mask solved this problem. A 1-month-old neonate with Pierre Robin syndrome and another with Treacher-Collins syndrome were scheduled for surgical fixation of the tongue to the mandible, for constant upper airway obstruction. In both patients, awake fiberoptic intubation was attempted but abandoned, because SpO(2) rapidly decreased during the attempts. Awake insertion of the laryngeal mask relieved upper airway obstruction and facilitated oxygenation. Fiberoptic intubation through the laryngeal mask was easily achieved. Anesthesia was then induced. No hypoxia occurred after insertion of the laryngeal mask. In a further two neonates with Treacher-Collins syndrome and in one neonate with Pierre Robin syndrome, awake fiberoptic intubation through the laryngeal mask was also successful. We believe that in neonates with predicted difficult intubation, who are at risk of upper airway obstruction and awake fiberoptic intubation could aggregate hypoxia, awake insertion of the laryngeal mask can be useful in facilitating oxygenation (by relieving upper airway obstruction) and in facilitating fiberoptic intubation.     

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.     

Awake tracheal intubation through the intubating laryngeal mask

PURPOSE: To report successful awake insertion of the intubating laryngeal mask (Fastrach) and subsequent tracheal intubation through it, in a patient with predicted difficult tracheal intubation, due to limited mouth opening, and difficult ventilation through a facemask, due to a large mass at the corner of the mouth. CLINICAL FEATURES: A 53-yr-old woman with a large post-gangrenous mass on the right cheek to the angle of the mouth was scheduled for its resection. The right side of her face was damaged by a bomb attack followed by cancrum oris 50 yr ago. The distance between the incisors during maximum mouth opening was 2 cm and that between the gums on the right side < 1 cm. After preoxygenation and 50 micrograms fentanyl and 30 mg propofol i.v., propofol was infused at 2 mg.kg-1.hr-1. Lidocaine, 8%, was sprayed on the oropharynx. A #4 intubating laryngeal mask was inserted with a little difficulty. A fibrescope was passed through a 7.5-mm ID RAE tracheal tube, and the combination was easily passed through the laryngeal mask into the trachea. General ansthesia was then induced. Finally, the intubating laryngeal mask was removed, while the RAE tube was being stabilized using an uncuffed 6.0-mm ID tracheal tube. CONCLUSION: Awake tracheal intubation through the intubating laryngeal mask is a useful technique in patients with limited mouth opening in whom ventilation via a facemask is expected to be difficult.     

Use of the fibreoptic intubating LMA-CTrach in two patients with difficult airways

We report two patients with difficult airways who underwent tracheal intubation using the new fibreoptic intubating Laryngeal Mask Airway CTrach. The imaging technology of the LMA-CTrach was decisive in the management of these two patients. The first patient had lingual tonsillar hyperplasia, and an omega-shaped retroflexed epiglottis. The second patient had a C2-occipital fusion and was completely unable to extend her head. Given the anatomical difficulties encountered, it was likely that intubation would have been difficult or impossible through the LMA-Fastrach. The aim of this report is to describe the successful use of this new intubating laryngeal mask airway in these two challenging patients.     

Awake tracheal intubation through the intubating laryngeal mask airway in a patient with halo traction

PURPOSE: To report a case of awake tracheal intubation through the intubating laryngeal mask airway (ILMA) in a patient with halo traction. Clinical features: A 16-yr-old, 40 kg, boy with atlanto-occipital instability and halo traction was scheduled for surgery under general anesthesia. The head of the patient was fixed in a position of flexion and extension was impossible. Cranial magnetic resonance imaging revealed that pharyngeal and laryngeal axes were aligned, but that the oral axis was in an extreme divergent plane. The tongue and oropharynx were anesthetized with 10% lidocaine spray and bilateral superior laryngeal nerve blockade was performed. Under sedation, awake orotracheal intubation via ILMA was successful. Fibreoptic bronchoscopy has been recommended for awake tracheal intubation in such patients. Other techniques, such as use of the Bullard laryngoscope have been described also but awake tracheal intubation through the ILMA in patients with a halo device in situ has seldom been reported in the medical literature. CONCLUSION: Airway management of patients with cervical spine instability includes adequate preoperative evaluation of the airway and choosing the appropriate intubation technique. We suggest that the ILMA may be an adequate alternative for awake tracheal intubation in patients with an unstable cervical spine and cervical immobilization with a halo device.     

High frequency jet ventilation through the laryngeal mask airway in a critically obstructed airway

SUMMARY: A 72 year-old man with an anticipated difficult airway secondary to a large, obstructing supraglottic tumour was scheduled for a panendoscopy. An elective pre-induction transtracheal catheter was placed to allow oxygenation if airway maintenance proved difficult. Following induction of anaesthesia, tracheal intubation was impossible and ventilation via both a facepiece and a laryngeal mask airway became progressively more difficult. An emergency tracheostomy was attempted whilst oxygenation was maintained with transtracheal jet ventilation, but the position of the transtracheal catheter made tracheostomy impossible. The catheter was removed and high frequency jet ventilation was then used via the laryngeal mask airway to maintain oxygenation. To our knowledge, the use of high frequency jet ventilation through the laryngeal mask airway in a critically obstructed airway has not been described before.     

Anesthesia in an adult patient with tracheal hemangiomas: one-lung ventilation for lung lobectomy

Primary tracheal tumors are rare in adults, and careful airway management is required during anesthesia for affected patients. We report the case of a patient with tracheal hemangiomas undergoing nontracheal operation. A 61-year-old woman was scheduled for a lung operation. During preoperative examination, hemangiomas were detected on the tracheal mucosa. As she was asymptomatic and the degree of airway stenosis was small, treatment was not required for the hemangiomas, and left upper lobectomy for lung cancer was scheduled. After induction of general anesthesia, a regular tracheal tube was inserted under fiberoptic bronchoscopy, with care taken to prevent damage to the hemangiomas. An endobronchial blocker was inserted for one-lung ventilation. The operation was performed uneventfully, and the tracheal tube was replaced postoperatively with a laryngeal mask airway while the patient was under deep anesthesia and neuromuscular blockade. The mask was removed after confirming lack of bleeding from the hemangiomas. No hypoxia or other complications occurred during or after the operation.     

Fiberoptic nasopharyngoscopy for evaluating a potentially difficult airway in a patient with elevated intracranial pressure

A 62-year-old man with a left temporal lobe tumor was scheduled for a semiurgent craniotomy for tumor excision. Previously, the patient had a laryngeal carcinoma that was resected and treated with chemotherapy and radiotherapy and a history of laryngeal biopsy with awake fiberoptic intubation. Because a difficult airway was anticipated, awake fiberoptic nasopharyngoscopy of the airway was performed under topical anesthesia in the operating room. This revealed a narrow glottic opening with no supraglottic pathology or friable tissue. Based on these airway observations, we proceeded safely with intravenous induction and secured the airway in a controlled fashion, thereby minimizing the risk of increased intracranial pressure and catastrophic complications. Nasopharyngoscopy can be used safely to evaluate the upper airway to stratify airway management in patients with a history of head and neck cancer presenting for neurosurgical procedures in the setting of elevated intracranial pressure.