Fiberoptic tracheal intubation aided by jaw lifting in a patient with an epiglottic cyst

Epiglottic cyst is known to cause difficult intubation. We report a patient with an epiglottic cyst whose trachea was successfully intubated with the aid of fiberoptic bronchoscopy combined with the jaw lift maneuver. A 29-year-old patient was scheduled for lumbar disk hernia surgery. On the first occasion, surgery was cancelled since the patient was unexpectedly found to have an epiglottic cyst and tracheal intubation was not possible. Two weeks later, nasotracheal intubation guided by fiberoptic bronchoscopy under conscious sedation was planned. On the first attempt of bronchoscopy, the glottic view was obscured by the cyst displacing the epiglottis posteriorly. Next, we applied the jaw lift maneuver in conjunction with bronchoscopy. The maneuver improved the glottic view by clearing the epiglottis from the posterior pharyngeal wall and the patient's trachea was successfully intubated. Jaw lifting could be a useful adjunct to fiberoptic bronchoscopy for tracheal intubation in patients with epiglottic cysts.     

Fiberoptic intubation and laryngeal morbidity: a randomized controlled trial

BACKGROUND: Tracheal intubation with neuromuscular blocking agents is associated with a low incidence of minor vocal cord sequelae (8%). The aim of this noninferiority trial was to demonstrate that the frequency of vocal cord sequelae after fiberoptic intubation with a flexible silicone tube without neuromuscular blocking agents was less than 25% (maximum tolerable inferiority). METHODS: Two-hundred seventy patients were prospectively randomized to two groups. All intubations were performed by anesthesiologists with extensive experience in fiberoptic and conventional techniques. Fiberoptic nasotracheal intubation consisted of a bolus dose of 2 microg/kg fentanyl; 0.25 ml cocaine instillation, 10%, into nasal canals; cricothyroid injection of 2 ml lidocaine, 1%; bronchoscopy; administration of 0.3 mg/kg etomidate; and advancing a flexible silicone tube after loss of consciousness. Orotracheal intubation was performed with a polyvinyl chloride tube after induction with 2 microg/kg fentanyl, 2 mg/kg propofol, and 0.6 mg/kg rocuronium. Patients were examined by laryngoscopy before surgery, 24 h after surgery, and daily until complete restitution. Postoperative hoarseness was assessed by a standardized interview. RESULTS: The incidence of vocal cord sequelae was 11 out of 130 (8.5%) in the fiberoptic group versus 12 out of 129 (9.3%) in the control group (chi-square = 0.057, df = 1, P = 0.81; upper limit of the one-sided 95% confidence interval for the difference: +5.1%). There were no persistent injuries. The incidence of postoperative hoarseness was 4% in both groups. CONCLUSIONS: Because fiberoptic intubation without neuromuscular blocking agents is safe regarding vocal cord sequelae, routine use is justified for anesthesiologists experienced in this technique.     

Fiberoptic tracheal intubation through a laryngeal mask airway in a child with Treacher Collins syndrome

Treacher Collins syndrome (TCS) is a rare inherited condition characterized by bilateral and symmetric abnormalities of structures within the first and second bronchial arches. The mechanism of inheritance is autosomal dominant with variable expressivity. Because of this variability in expression, some affected individuals exhibit virtually no overt clinical manifestations. However, most children with TCS present with the following classic facial features: down-sloping palpebral fissures, colobomata of the lower eyelid, scanty lower eyelashes, malar hypoplasia, and micro- or retrognathia. Cleft palate is present in up to 35% of patients and an additional 30-40% have congenital palatopharyngeal incompetence. Abnormalities of the ear are very common and vary from minor malformations to severe microtia and hearing loss. Hearing loss may be due to atresia of the auditory canals or ossicular malformation of the middle ear. Despite these many development abnormalities, TCS patients are usually of normal intelligence. We report the case of a 3 1/2-yr-old patient with TCS undergoing cleft palate repair and discuss fiberoptic intubation through a laryngeal mask airway using two endotracheal (ETT) tubes secured via an ETT connector.     

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.     

Gastric rupture after awake fibreoptic intubation in a patient with laryngeal carcinoma

An 86-yr-old man with recurrent laryngeal carcinoma developedgastric rupture after awake fibreoptic intubation before inductionof general anaesthesia. Early clinical signs included a distended,tense and tympanic abdomen with pain and massive pneumoperitoneum(chest radiograph). Laparotomy revealed a 4-cm longitudinalperforation along the lesser curvature of the stomach. Thiscase represents a rare but severe complication that may occurduring fibreoptic intubation in the awake patient.     

Fiberoptic intubation via laryngeal mask airway under general anesthesia in the patients with halo vest

Since 1991, we gave anesthesia to 155 patients with halo vest. All of 128 whose airways could be kept patent by laryngeal mask airway (LMA) were successfully intubated fiberoptically via LMA using the tube exchange catheter under general anesthesia. Four patients developed airway obstruction during the induction of anesthesia, two of whom were awakened and subsequently intubated by awake fiberoptic intubation. In one patient LMA could keep the airway patent. In the other patient, cervical immobilization by halo device was released and the intubation was performed with a laryngoscope. For 8 patients, awake fiberoptic intubation was chosen from the preoperative evaluation of the positioning of head and neck. Fifteen patients were intubated with a laryngoscope without trying LMA fiberoptic intubation. No patient developed neurological injury attributed to the intubation. LMA fiberoptic intubation has several advantages. Patients do not feel discomfort under general anesthesia. Ventilation is kept continued until LMA is removed. Even less experienced residents can intubate easily and safely without assistance. However, we must carefully diagnose and select the patient whose airway can be kept patent under general anesthesia. The motionless pictures of the intubation procedures can be seen on the web site: www.hosp.go.jp/~kobe/.     

Fiberoptic intubation using intraoral glossopharyngeal nerve block in a patient with severe preeclampsia and HELLP syndrome

Rationale and technique for use of intraoral glossopharyngeal nerve block is described in a parturient with severe preeclampsia and a past history of difficult intubation. Indications and contraindications for administration of other forms of airway anesthesia are discussed.     

Fiberoptic intubation through laryngeal mask airway with an innovated tube under 5% sevoflurane anesthesia

BACKGROUND : Previously we had reported an intubation method using 52 cm innovated tube (I. D.=5.0) for patients with difficult airways, but hemodynamic change and anesthetic level were not evaluated during this procedure. In the present report we investigated heart rate, mean arterial pressure and bispectral index (BIS) during this procedure under volatile induction and maintainance of anesthesia (VIMA) with 5% sevoflurane without muscle relaxant. METHODS : We enrolled 6 patients considered having difficult airway. Airway management was performed under VIMA of 5% sevoflurane. After insertion of a laryngealmask airway (LMA), 52 cm-tube was intubated through LMA under bronchofiberscope. After LMA was removed, the endotracheal tube was passed through the 52 cm-tube into the trachea. Hemodynamic change was recorded at 1 min intervals and BIS at 5 sec intervals until 3 min after securing their airways. RESULTS : VIMA of 5% sevoflurane provides stable hemodynamic state during the procedure and suppressed body movement sufficiently on tracheal intubation. BIS was elevated due to cough on intubation in 4 cases. However no patient recalled the procedure. CONCLUSIONS : Sevoflurane 5% suppressed hemodynamic changes sufficiently with this procedure without muscle relaxants.     

Retromolar fibreoptic orotracheal intubation in a patient with severe trismus undergoing nasal surgery

Purpose

A considerable challenge arises when passage of an endotracheal tube between the teeth is impossible because of severe trismus and the presence of concomitant contraindications to nasotracheal intubation. We report a novel technique to circumvent the need for tracheostomy by using the retromolar space for oral fibreoptic intubation.

Clinical features

A 50-yr-old female with a history of pharyngeal cancers treated with surgery and radiotherapy presented for right dacryocystorhinostomy. She had undergone left dacryocystorhinostomy after nasotracheal intubation one week earlier. This time, orotracheal intubation was requested since surgery would involve the right nostril and left nasal intubation might dislodge the recently placed nasolacrimal tube. Due to severe trismus, the patient’s interincisor distance was only 9 mm, and it was impossible to pass a 6.0 mm endotracheal tube through that gap. A flexible bronchoscope loaded with a 6.0 mm tracheal tube was inserted through the retromolar space into the pharynx and maneuvered through the vocal cords for endotracheal intubation.

Conclusions

The retromolar space is located between the last molar and the ascending ramus of the mandible. Even with complete mandibular occlusion, it is usually able to accommodate a 7.0 mm endotracheal tube. Despite its hidden location, it can be used successfully for orotracheal fibreoptic intubation. With practice, the expertise achieved in performing this technique will confer a much needed option for securing the airway in this challenging situation.     

Lighted stylet-guided intubation via the intubating laryngeal airway in a patient with Hallermann-Streiff syndrome

Purpose

Hallermann-Streiff syndrome is a congenital syndrome associated with oculomandibulofacial abnormalities and potentially difficult airways. This case report describes the novel use of a lighted stylet-guided tracheal tube insertion through a new supraglottic airway, the intubating laryngeal airway (ILA?), in a patient with Hallermann-Streiff syndrome who had anticipated difficult airway.

Clinical features

A 26-year-old male with Hallermann-Streiff syndrome was scheduled for a vitrectomy. The patient had mandibulofacial dystocia with a bird-like appearance, a mouth opening of 4 cm, a receding chin, and a Mallampati class 3 examination. The surgeon requested muscle paralysis and no movement during surgery. After receiving midazolam, fentanyl and propofol, a size 3.5 ILA? was inserted and lung ventilation was easy to perform. A 7.5-mm internal diameter tracheal tube was mounted on a lighted stylet with its inner rigid stylet removed. After succinylcholine administration, the lighted stylet-tracheal tube assembly was inserted via the ILA? until the transillumination just vanished below the sternal notch. The lighted stylet was removed, the circuit was connected, and capnography confirmed tracheal placement of tube. The ILA? was deflated and left in situ. Upon emergence from anesthesia, the tracheal tube, and subsequently the ILA?, were removed without complications.

Conclusions

This case presents a novel use of a lighted stylet-guided tracheal tube insertion through the ILA? in a patient with Hallermann-Streiff syndrome. This intubation technique can be considered in patients with difficult airways as a primary route of intubation, or as a secondary rescue strategy.     

Awake tracheal intubation with the intubating laryngeal mask in a patient with diffuse idiopathic skeletal hyperostosis

Diffuse idiopathic skeletal hyperostosis, otherwise known as Forestier's disease or ankylosing hyperostosis, is a relatively common condition that is distinguished from ankylosing spondylitis by the relative preservation of spinal function and the characteristic 'candle flame' lipping of the vertebrae. We report a patient with this condition and a well-recorded history of impossible intubation who presented for emergency laparotomy. The patient was intubated awake using the intubating laryngeal mask and sedation and anaesthesia were provided by a target-controlled infusion of propofol.