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Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 104-107

Misleading endoscopic airway images – Who does the examination matters!!!

Department of Anaesthesiology and Pain Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission28-Mar-2021
Date of Acceptance28-Apr-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Gautham Ganesan
A301, Newry Celio, Poonamallee Avadi High Road, Paruthipattu, Chennai - 600 071, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_16_21

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We report a 38-year-old female, post-oesophagectomy with transposed colon, presenting with dysphagia for oesophageal dilatation. General anaesthesia was requested for as the patient did not tolerate previous dilatation attempts under local anaesthesia. Endoscopic images provided by the otorhinolaryngologists and gastroenterologists showed a good view of the glottis, suggesting a possible easy intubation. But direct laryngoscopy after sedation and airway topicalisation revealed an airway with extensive adhesions that would have been impossible to intubate. The patient was awakened and planned for the procedure after tracheostomy. Endoscopic images done by non-anaesthesiologists should be interpreted with caution.

Keywords: Airway adhesion, endoscopic examination, supraglottic stenosis

How to cite this article:
Ganesan G, Dhanasekaran R. Misleading endoscopic airway images – Who does the examination matters!!!. Airway 2021;4:104-7

How to cite this URL:
Ganesan G, Dhanasekaran R. Misleading endoscopic airway images – Who does the examination matters!!!. Airway [serial online] 2021 [cited 2021 Dec 2];4:104-7. Available from: https://www.arwy.org/text.asp?2021/4/2/104/323566

  Introduction Top

Supraglottic strictures/adhesions following corrosive consumption is a widely prevalent problem both in developed and developing countries. Such patients are usually tracheostomised and the upper airway anatomy is seldom carefully evaluated. Our case highlights the need for a proper airway assessment in cases of supraglottic adhesions and pitfalls in airway assessment done by non-anaesthesiologists. It also emphasises the need for endoscopic airway assessment by an anaesthesiologist for formulating a better airway management plan.

  Case Report Top

A 38-year-old female, a case of 'oesophageal stricture' in the interposed colon, was posted for oesophageal dilatation under general anaesthesia (GA). A case of suicidal corrosive consumption with severe dysphagia, she underwent transhiatal oesophagectomy with colonic interposition and coloplasty in 2004. The patient was asymptomatic till 2018 when she consulted an otorhinolaryngologist for recurrence of dysphagia. As the flexible fibreoptic laryngoscope (FOL) revealed extensive supraglottic adhesions, it was decided to proceed with release of adhesions. The procedure was done 3 months prior to the current oesophageal dilatation under tracheostomy performed under local anaesthesia. The tracheostomy tube was decannulated a week later.

After 2 months, oesophageal dilatation was attempted by the gastroenterologist under topical anaesthesia. The procedure was unsuccessful as the patient was uncooperative and technical difficulties were also encountered. The patient was rescheduled for the same procedure 2 weeks later under GA.

Preoperative examination revealed an American Society of Anesthesiologists II patient (anaemia) with hoarseness of voice. Review of fibreoptic laryngoscopic (FOL) images revealed multiple adhesions with distorted anatomy prior to release of adhesions [Figure 1] with a significantly better view of vocal cords after release of adhesions [Figure 2]. Patient also reported easy breathing following adhesiolysis. The upper gastrointestinal (UGI) endoscopy performed by the gastroenterologist after the adhesions were release also revealed a satisfactory view of the glottis [Figure 3].
Figure 1: Adherent epiglottis

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Figure 2: Glottic view beyond adherent epiglottis

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Figure 3: Images recorded by gastroenterologist do not show the epiglottis

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On the day of the procedure, adequate fasting was ensured. Baseline monitoring consisting of a 5-electrode electrocardiogram, noninvasive blood pressure and pulse oximetry were established. As the patient was clinically asymptomatic and the FOL and UGI endoscopy revealed adequate view of the glottis, it was planned to proceed with inhalation induction using sevoflurane, preserving spontaneous ventilation and performing a check laryngoscopy. Microlaryngeal surgery (MLS) tubes of size 4 and 5 mm ID were kept ready. Local anaesthetic (10% lignocaine spray) was administered with an atomiser. The patient was preoxygenated with 100% oxygen for 3 min. Anaesthetic induction was started with sevoflurane (3%) in 100% oxygen, with serial increments in inhaled concentration by 1% every 4–5 breaths until 8% inhaled sevoflurane was being administered. After loss of eyelash reflex, direct laryngoscopy was performed. There were extensive adhesions in the oropharynx and hypopharynx, and the epiglottis was found to be tethered to the posterior part of the tongue. There was a small opening through which the vocal cords could not be visualised. The upper end of 'oesophagus' was also not seen. It was decided not to proceed further and the anaesthetic was terminated with the patient being assisted gently with a pressure support of 10 cm H2O and the procedure was deferred. An ENT consultation was sought following which adhesiolysis and stricture dilatation were performed under GA following an awake tracheostomy.

  Discussion Top

Supraglottic stenosis/pathology of upper airway is encountered quite commonly in anaesthetic practice, though the majority of patients have a tracheostomy in situ or performed before anaesthetic induction.[1] The airway implications are therefore less appreciated.

Involvement of the lower airway following corrosive ingestion are not very common due to protective mechanisms of pharynx and glottis.[2] Endoscopic airway examination is considered a useful adjunct to airway assessment. In this patient, though the FOL showed dense adhesion between the epiglottis (E) and the posterior tongue [Figure 1], the post-adhesiolysis image [Figure 2] showed a satisfactory view of the glottis with a narrowed 'oesophagus' (indicated by a red arrow). Re-epithelialisation after mucosal injury takes 7–10 days,[3] and any delay in the process can predispose to early formation of adhesions. The other airway concerns in this patient were an altered anatomy for performing emergency surgical airway access due to the transposed colon and a risk of aspiration of oropharyngeal secretions. The patient had been tracheostomised and decannulated twice. A puckered tracheostomy scar was noted [Figure 4]. Though the patient was asymptomatic, the possibility of subglottic stenosis was also kept in mind,[4] and MLS tubes were kept ready.
Figure 4: Puckered tracheostomy scar

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But direct laryngoscopy revealed difficult intubation in view of unexpected recurrent supraglottic adhesions obscuring laryngeal and oesophageal inlets, possibly due to inadequate adhesiolysis or the rare re-development of adhesions in a short duration. The FOL and UGI scopy images and relief of symptoms after adhesiolysis could be deceptive. The difference in glottic visualisation implies that the initial adhesions were subsequently bypassed during FOL and UGI scopy, leading to a reassuring glottic view. Otorhinolaryngologists use angulated 70° endoscopes which might give a good glottic view but may still present difficulties during tracheal intubation.

Another point to be remembered is that images captured by non-anaesthesiologists may concentrate on the areas of their interest rather than the airway in entirety. Rosenblatt reported a reduction in the number of awake intubations following preoperative endoscopic airway assessment by indirect laryngoscopy.[5] The presence of previous difficult airway indicators including corrosive ingestion, adhesions, adhesiolysis, tracheostomy and coloplasty should prompt the anaesthesiologist for a backup plan such as awake videolaryngoscopic evaluation under topical anaesthesia with an angulated blade, evaluation with Hopkins rod lens system or awake fibreoptic examination of the airway prior to anaesthetic induction. The endoscopy images should be read in conjunction with clinical assessment. This case has particularly emphasised the need for caution while interpreting endoscopic airway assessment by non-anaesthesiologists.

Passage of an endotracheal tube across the narrow opening might injure the larynx[6] and cause bleeding. Use of a fibreoptic bronchoscope can cause total airway obstruction once the hypopharyngeal opening is occluded by the bronchoscope ('cork in the bottle' effect).[6] Use of jet ventilation may not be safe as there would be obstruction to passive expiration. The expired air can also track down into the digestive tract and increase the risk of aspiration. Managing a case of difficult airway outside an operating room setting is challenging. Unfamiliar environment, delay in availability of airway adjuncts and expert help, communication gap between endoscopists and the anaesthesiologists, lack of working space and sharing the airway warrants careful planning for airway management, more so if the airway is difficult.

  Conclusion Top

Endoscopic airway images provided by non-anaesthesiologists must be interpreted with caution. Preoperative endoscopic airway examination focussing on airway assessment by anaesthesiologists or along with primary care physicians will give valuable information in patients with suspected upper airway pathology.

Declaration of patient consent

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

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Tseng YL, Wu MH, Lin MY, Lai WW. Massive upper gastrointestinal bleeding after acid-corrosive injury. World J Surg 2004;28:50-4.  Back to cited text no. 1
Contini S, Scarpignato C. Caustic injury of the upper gastrointestinal tract: A comprehensive review. World J Gastroenterol 2013;19:3918-30.  Back to cited text no. 2
Mohajerani H, Karimi F, Mohajerani A, Rakhshan V. Incidence and risk factors of functional upper airway complications of primary esthetic closed rhinoplasty in two residency programs: A 6-month preliminary prospective cohort study. Dent Res J (Isfahan) 2013;10:74-80.  Back to cited text no. 3
Rosenblatt W, Ianus AI, Sukhupragarn W, Fickenscher A, Sasaki C. Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation. Anesth Analg 2011;112:602-7.  Back to cited text no. 4
Divatia JV, Bhowmick K. Complications of endotracheal intubation and other airway management procedures. Indian J Anaesth 2005;49:308-18.  Back to cited text no. 5
  [Full text]  
Nekhendzy V, Kristensen MS, Claure RE. Anesthetic and airway management of microlaryngeal surgery and upper airway endoscopy. In: Benumof J, Hagberg CA, editors. Benumof and Hagberg's Airway Management. 3rd ed. Phidaelphia, PA: Elsevier/Saunders; 2013.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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