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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 117-120

Management of anticipated difficult airway in a case of neurofibromatosis during the COVID-19 pandemic

Department of Anesthesiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission21-Apr-2021
Date of Acceptance24-Jun-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Jhanvi S Bajaj
Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra - 400 016
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_22_21

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Neurofibromata with a potential to affect the airway occur mostly in the head, neck, face and larynx, posing a risk to the airway and making intubation difficult. Management of an anticipated difficult airway needs special precautions and airway protection strategies during the COVID-19 pandemic. A 50-year-old woman was scheduled for excision of cervical neurofibroma measuring 6.6 cm × 7.2 cm on the right side of nape of neck, resulting in limited neck extension. We decided to intubate this patient under anaesthesia as against an awake fibreoptic intubation for three reasons. Our patient was not willing for awake intubation,we wanted to prevent aerosolisation during intubation and computerised tomography of the chest showed signs of postinfective sequelae probably suggestive of a lower respiratory tract infection. All precautions to protect the airway operator from aerosol exposure were followed such as using an aerosol box and a videolaryngoscope. Our case highlights the importance of collaborative decision-making, careful preparation and thorough management of anticipated difficult airway in neurosurgery patients during the COVID pandemic.

Keywords: Aerosol box, COVID-19, difficult airway, videolaryngoscope

How to cite this article:
Bajaj JS, Shetty AN, Devalkar P. Management of anticipated difficult airway in a case of neurofibromatosis during the COVID-19 pandemic. Airway 2021;4:117-20

How to cite this URL:
Bajaj JS, Shetty AN, Devalkar P. Management of anticipated difficult airway in a case of neurofibromatosis during the COVID-19 pandemic. Airway [serial online] 2021 [cited 2021 Dec 2];4:117-20. Available from: https://www.arwy.org/text.asp?2021/4/2/117/323569

  Introduction Top

Neurofibromatosis constitutes a group of autosomal dominant disorders with a tendency of formation of neurofibromas or nerve sheath tumours all over the body. This disease occurs in 1:3000 births and represents the most common type of neurocutaneous syndrome.[1] Plexiform neurofibromas occur mostly in the head, neck, face and larynx, posing a risk to the airway and making intubation difficult.[2] Airway management during surgery for excision of neurofibroma, whether awake or sedated, exposes operators to infectious aerosols, posing risks to staff, especially during the COVID-19 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) pandemic. Thus, special precautions and airway protection strategies need to be followed during this period while handling a difficult airway. We report a case which illustrates the novel management of an anticipated difficult airway during the COVID-19 pandemic in a patient with cervical neurofibroma using an aerosol protection box and videolaryngoscope.

  Case Report Top

A 50-year-old woman (60 kg) was scheduled for excision of cervical neurofibroma over the right nape of the neck [Figure 1]. Magnetic resonance image (MRI) neck showed a 6.6 cm × 7.2 cm mass extending onto the C2–C3 vertebrae but not involving the vertebrae [Figure 2]. Airway examination revealed normal mouth opening, dentition and temporomandibular joint movements. Her airway was classified as Mallampati class II. Neck extension was limited due to the presence of the mass. Chest X-ray, computerised tomography (CT) scan of head/brain and echocardiography were within normal limits. CT thorax showed bilateral lung lesions, suggestive of postinfectious sequelae. Other relevant investigations were within normal limits. She reported no fever or upper respiratory symptoms, and COVID-19 reverse transcription polymerase chain reaction test (RT-PCR) was negative on admission. Her cardiorespiratory systems were unremarkable. The patient was accepted for excision of cervical neurofibroma as American Society of Anesthesiologists Physical Status II and the procedure was planned under general anaesthesia.
Figure 1: Cervical neurofibroma over the nape of the neck

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Figure 2: Magnetic resonance image of the head and neck showing mass adjacent to C3 and C4

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As per hospital guidelines, while aerosol-generating procedures such as intubation are being performed (even in COVID-negative patients), all staff need to wear personal protective equipment. Preoperative preparation included establishing monitors such as electrocardiogram, noninvasive blood pressure, pulse oximeter and surface temperature before securing intravenous access in the right upper limb with an 18 SWG cannula. The saturation on room air was 97%. We decided to intubate this patient under anaesthesia as against an awake fibreoptic intubation (FOI) due to three reasons. Our patient was not willing for awake intubation,we wanted to prevent aerosolisation during intubation and computerised tomography of the chest showed signs of postinfective sequelae probably suggestive of a lower respiratory tract infection. A difficult airway cart including rigid and flexible fibrescopes as well as apparatus for possible emergent surgical cricothyroidotomy was kept ready. The patient was explained the need for placing an aerosol protection box [Figure 3] around her head during induction of anaesthesia. The patient was preoxygenated with 100% oxygen for 3 min followed by rapid sequence induction using injection succinylcholine. A videolaryngoscope was used for intubation to avoid looking directly into the patient's airway which further increases the chances of the operator inhaling an infected aerosol. Grade II Cormack–Lehane laryngeal view was obtained, and the patient intubated with a 7.5 mm ID endotracheal tube. After confirming correct endotracheal tube placement by capnography, a long-acting neuromuscular blocking agent was given and the patient placed on volume-controlled mode of ventilation. The perioperative period was uneventful.
Figure 3: Aerosol protection box in use

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Our backup plan in case of failure to intubate by conventional laryngoscopy was to attempt intubation with a videolaryngoscope after removing the aerosol box. Adequate precautions in the form of personal protective equipment to prevent transmission of infection were already in use as per hospital protocol. If difficulty still persisted, our choice would have been to ventilate the patient with a tight-fitting mask or a supraglottic airway device, awaken her and counsel her to accept awake fibreoptic-aided intubation on a later occasion.

  Discussion Top

This case illustrates two challenges - one presented by the COVID-19 pandemic and the other, a difficult airway created by a cervical neurofibroma. Plexiform neurofibromas are the hallmark lesions of neurofibromatosis-1 (NF1). These occur in 30% of NF1 patients, are usually congenital and affect long segments of the involved nerve. They may infiltrate the nerve and the surrounding tissue and may give rise to extensive disfiguration. Painless dislocation of the cervical vertebrae has been reported in a patient with multiple cervical neurofibromas, and it has been suggested that radiographic examination of the neck should be performed before anaesthesia in these patients to avoid spinal cord damage during laryngoscopy and tracheal intubation.[3] In our case, the patient had limited neck extension and side-to-side movements. However, the MRI neck did not show any breach of cervical vertebrae.

We therefore decided to use a videolaryngoscope for intubation as it enables laryngoscopy without the need to obtain alignment of the oral, pharyngeal and laryngeal axes.[4] In addition, a videolaryngoscope keeps the operator at a safe distance from the patient's face. We refrained from using FOI in this patient because of two reasons – patient refusal for an awake intubation and categorisation of FOI as a high-risk procedure for aerosolisation because of the high probability of coughing and dissemination of virus particles.[5] Use of a negative pressure intubation hood, especially designed for FOI, has been described in literature by Emery et al.[6]

Tracheal intubation is a high risk aerosol-generating procedure due to direct exposure to the airway and the potential for coughing during induction.[7],[8] The COVID-19 pandemic has led to the production of novel devices to protect anaesthesiologists during this procedure. The aerosol protection box was originally designed by a Taiwanese doctor as a low cost and easy to set up device that restricts the sphere within which the exhaled aerosols would be retained.[9],[10] Even though our patient was negative for COVID-19, we took into consideration an account by Li et al. that reported a high false-negative rate of real-time RT-PCR results for SARS-CoV-2 detection.[11] Due to this, hospitals across the globe including our hospital have been following standard precautions against COVID-19 during the pandemic even in patients who have tested negative preoperatively.

In a study by Fong et al. in simulated difficult airway scenarios, the use of the aerosol box increased time to intubation by 7 s.[12] Any increased time required to perform the procedure directly leads to an increased risk of hypoxia and negative outcomes. In addition, they did not take into account the increase in optimisation manoeuvres, intubation attempts and failed intubations in a difficult airway scenario. Ellison et al. conducted a survey on the use of the airway box and found that 54% of the providers felt the device increased safety from exposure while only 16% found the device to decrease safety, thus giving healthcare providers mental satisfaction of additional safety against the virus.[13] Even though research from Melbourne, Australia, found that aerosolisation boxes may increase airborne particles through the holes in the box, there have been arguments stating that particle concentration in the air is significantly affected by air circulation, humidity and atmospheric pressure within the room.[14] The air within an operating room typically exchanges 18–26 times per hour which helps alleviate some of the risks that may result from using the aerosol box. Thus, the risk–reward ratio needs to be calculated before using the aerosol box for securing difficult airway.

The aerosol box presents its own share of limitations. The participants in the study by Fong et al. also noted that the rigid cut-outs of the box decreased arm manoeuverability and the height of the aerosol box impeded the use of the intubating stylet and bougie.[12] Gould et al. used the intubation box in a simulation setting and found that the presence of a physical barrier increased the difficulty of tracheal intubation, especially during transition between airway devices and when using intubation adjuncts.[15]

The issues discussed in this case apply not only to intubation but also to other airway-related procedures such as tracheostomy, endoscopy and fibreoptic bronchoscopy. Undoubtedly, management of an anticipated difficult airway is a major dilemma during this pandemic. Our case highlights the importance of collaborative decision-making, careful preparation and thorough management of an anticipated difficult airway in neurosurgical patients during the COVID pandemic.

Declaration of patient consent

The authors certify that they have obtained the appropriate patient consent form. In the form, the patient has given her consent for her 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 her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Shekar V, Rangdhol V, Baliah WJ, Thirunavukarasu S. An unusual oral manifestation of type 1 neurofibromatosis: A case report and review of literature. J Nat Sci Biol Med 2015;6:261-3.  Back to cited text no. 1
Wise JB, Cryer JE, Belasco JB, Jacobs I, Elden L. Management of head and neck plexiform neurofibromas in pediatric patients with neurofibromatosis type 1. Arch Otolaryngol Head Neck Surg 2005;131:712-8.  Back to cited text no. 2
Lovell AT, Alexander R, Grundy EM. Silent, unstable, cervical spine injury in multiple neurofibromatosis. Anaesthesia 1994;49:453-4.  Back to cited text no. 3
Koyama J, Aoyama T, Kusano Y, Seguchi T, Kawagishi K, Iwashita T, et al. Description and first clinical application of AirWay Scope for tracheal intubation. J Neurosurg Anesthesiol 2006;18:247-50.  Back to cited text no. 4
Zuo MZ, Huang YG, Ma WH, Xue ZG, Zhang JQ, Gong YH, et al. Expert recommendations for tracheal intubation in critically ill patients with noval coronavirus disease 2019. Chin Med Sci J 2020;35:105-9.  Back to cited text no. 5
Emery AR, Saniukovich O, Lang AL, Tannyhill RJ 3rd, Wang J. A novel approach to fiberoptic intubation in patients with coronavirus disease 2019. J Oral Maxillofac Surg 2020;78:2182.e1-6.  Back to cited text no. 6
Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS One 2012;7:e35797.  Back to cited text no. 7
Greig PR, Carvalho C, El-Boghdadly K, Ramessur S. Safety testing improvised COVID-19 personal protective equipment based on a modified full-face snorkel mask. Anaesthesia 2020;75:970-1.  Back to cited text no. 8
Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R. Barrier enclosure during endotracheal intubation. N Engl J Med 2020;382:1957-8.  Back to cited text no. 9
Bianco F, Ranieri AJ, Paterniti G, Pata F, Gallo G. Acute intestinal ischemia in a patient with COVID-19. Tech Coloproctol 2020;24:1217-8.  Back to cited text no. 10
Li Y, Yao L, Li J, Chen L, Song Y, Cai Z, et al. Stability issues of RT-PCR testing of SARS-CoV-2 for hospitalized patients clinically diagnosed with COVID-19. J Med Virol 2020;92:903-8.  Back to cited text no. 11
Fong S, Li E, Violato E, Reid A, Gu Y. Impact of aerosol box on intubation during COVID-19: A simulation study of normal and difficult airways. Can J Anaesth 2021;68:496-504.  Back to cited text no. 12
Ellison P, Nanners B, Schaefer G, Krueger A, Dhumak V, Shepherd JL, et al. Will protective innovations like the “Airway Box” become routine practice after the pandemic? An opinion survey. Cureus 2021;13:e13258.  Back to cited text no. 13
Simpson JP, Wong DN, Verco L, Carter R, Dzidowski M, Chan PY. Measurement of airborne particle exposure during simulated tracheal intubation using various proposed aerosol containment devices during the COVID-19 pandemic. Anaesthesia 2020;75:1587-95.  Back to cited text no. 14
Gould CL, Alexander PD, Allen CN, McGrath BA, Shelton CL. Protecting staff and patients during airway management in the COVID-19 pandemic: Are intubation boxes safe? Br J Anaesth 2020;125:e292-3.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3]


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