Difficult airway where the anaesthesiologist succeeded but not the operating otorhinolaryngologist

Ananda Bangera; Tejanand K; Sowmyashree K

doi:10.4103/arwy.arwy_38_20

CASE REPORT

Year : 2020 | Volume : 3 | Issue : 3 | Page : 151-153

Difficult airway where the anaesthesiologist succeeded but not the operating otorhinolaryngologist

Ananda Bangera, Tejanand K, Sowmyashree K
Department of Anaesthesiology and Critical Care, K S Hedge Medical Academy, NITTE Deemed to be University, Mangaluru, Karnataka, India

Date of Submission	18-Sep-2020
Date of Acceptance	17-Nov-2020
Date of Web Publication	25-Dec-2020

Correspondence Address:
Dr. Tejanand K
Department of Anaesthesiology and Critical Care, K S Hedge Medical Academy, NITTE Deemed to be University, Mangaluru, Karnataka - 575 018
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_38_20

Abstract

Difficult laryngoscopy and intubation are life-threatening situations that are commonly seen in obese, short-necked patients. Amongst the various tools that can facilitate successful intubation in such patients, awake fibreoptic intubation is possibly the most popular and safe method. Rarely, the airway abnormality may be so severe that the operating otorhinolaryngologist may face difficulties in performing surgery once the airway has been secured, as happened in our patient.

Keywords: Difficult laryngoscopy, fibreoptic intubation, microlaryngeal surgery

How to cite this article:
Bangera A, Tejanand K, Sowmyashree K. Difficult airway where the anaesthesiologist succeeded but not the operating otorhinolaryngologist. Airway 2020;3:151-3

How to cite this URL:
Bangera A, Tejanand K, Sowmyashree K. Difficult airway where the anaesthesiologist succeeded but not the operating otorhinolaryngologist. Airway [serial online] 2020 [cited 2023 Jun 7];3:151-3. Available from: https://www.arwy.org/text.asp?2020/3/3/151/304847

Introduction

The incidence of difficult tracheal intubation has been estimated at 1.5%–8%.^[1] Intubation in obese short-necked patients with anticipated difficult airway is challenging.^[2] Awake fibreoptic intubation, considered the gold standard, remains an invaluable choice for management of these cases, often making intubation look straightforward.^[3] However, there is a lack of awareness about difficult airway amongst other surgical specialities. We present a case where the otorhinolaryngologist could not proceed with the planned surgery after the anaesthesiologist had secured the airway because he could not visualise and approach the vocal cords to perform surgery due to a very severe degree of difficult laryngoscopy.

Case Report

A 42-year-old obese male with a body mass index of 35.55 kg/m² was scheduled for microlaryngoscopy and excisional biopsy of a vocal cord polyp. The procedure was first attempted at a private nursing home but was cancelled as multiple attempts at intubation were unsuccessful.

Airway examination revealed a mouth opening of 2 fingers; thyromental distance of 5 cm; neck circumference of 49 cm and a short, thick and stiff neck with reduced neck movements. The patient had an intact dentition and even the hard palate could not be visualised [Figure 1]. We could probably describe this patient as having an airway that is worse than Mallampati class IV (we suggest Mallampati class V as an additional entity where even the hard palate is not visualised). Because of the above-mentioned factors, it was considered as an anticipated difficult airway and awake fibreoptic nasotracheal intubation was planned under topical airway anaesthesia. Under mild sedation (midazolam 2 mg IV) and intramuscular glycopyrrolate, the airway was anaesthetised with lignocaine-soaked nasal pledgets, lignocaine nebulisation and superior and recurrent laryngeal nerve blocks (transtracheal injection). Awake nasotracheal intubation was performed under fibreoptic guidance using a 6.5 mm ID armoured reinforced tracheal tube. Once the airway was secured, the patient was anaesthetised with injection propofol and paralysed with atracurium before handing over to the surgeon.

Figure 1: Airway examination and assessment. (a) mouth opening of 2 fingers, (b) thyromental distance of 5 cm and neck circumference of 49 cm, (c) Mallampati class assessment (hard palate not visualized)

Click here to view

After proper positioning of the patient with a shoulder roll, the seniormost otorhinolaryngologist started the procedure, but the glottis could not be visualised. Different manoeuvres such as placement of an extra pillow under the shoulder, removing the pillow and using a no-pillow technique, use of different sizes of microlaryngoscope blades, use of other laryngoscopes including Macintosh laryngoscope and administration of additional doses of muscle relaxants failed to aid in the visualisation of any part of the vocal cords. The procedure was finally abandoned and the patient was extubated when he was fully awake. He was shifted to the postanaesthesia care unit after administration of intravenous dexamethasone.

Discussion

Difficult airway represents a complex correlation between patient factors, the clinical set-up and most importantly the skill of the anaesthesiologist and operating surgeon.^[4] This is a potentially life-threatening situation in anaesthetic practice.^[5] However, with different methods of identifying this and with the availability of a variety of techniques such as videolaryngoscopes, intubating aids and fibreoptic bronchoscope, we are often able to intubate these patients and manage the airway under topical anaesthesia without taking the risk of anaesthetising and paralysing the patient. Although we could intubate our patient in an awake state using fibreoptic-guided nasotracheal intubation under topical anaesthesia, the surgeon could not operate and excise the vocal cord polyp as he was unable to visualise the glottic area even after multiple manoeuvres and using different surgical equipment.

The incidence of difficult intubation is reported to be higher in patients posted for otorhinolaryngological procedures.^[6] In this short-necked and obese patient, the larynx was probably too anterior and hence could not be accessed by the otorhinolaryngologist. The surgery was therefore abandoned. From our experience with this patient, we emphasise the need for a proper assessment of the airway by the concerned otorhinolaryngological surgeon before operating. Our patient had undergone an evaluation in the outpatient department by the otorhinolaryngologist using a Hopkins^® rod-lens rigid nasal endoscope. We believe that in some patients such as ours, a joint evaluation by two specialists and formulation of an overall management strategy could help in avoiding unnecessary cancellation of such high-risk cases after having subjected the patient to potentially life-threatening airway-securing procedures.

Conclusion

We conclude that in some patients with a difficult airway posted for airway-related surgeries, a combined assessment by the anaesthesiologist as well as the otorhinolaryngologist before surgery and a discussion regarding airway management and possibility of difficulty in visualising the glottis for microlaryngoscopy is crucial for a successful outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Tamire T, Demelash H, Admasu W. Predictive values of preoperative tests for difficult laryngoscopy and intubation in adult patients at Tikur Anbessa Specialized Hospital. Anesthesiol Res Pract 2019;2019:1-13. [doi: 10.1155/2019/1790413].
2.	Wang T, Sun S, Huang S. The association of body mass index with difficult tracheal intubation management by direct laryngoscopy: A meta-analysis. BMC Anesthesiol 2018;18:79.
3.	Wong J, Lee JS, Wong TG, Iqbal R, Wong P. Fibreoptic intubation in airway management: A review article. Singapore Med J 2019;60:110-8.
4.	Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251-70.
5.	Popovici SE, Mitre C. Difficult airway management-A constant challenge. Rom J Anaesth Intensive Care 2018;25:93-4.
6.	Arnè J, Descoins P, Fusciardi J, Ingrand P, Ferrier B, Boudigues D, et al. Preoperative assessment for difficult intubation in general and ENT surgery: Predictive value of a clinical multivariate risk index. Br J Anaesth 1998;80:140-6.