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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 125-127

Awake nasal intubation using a videolaryngoscope: A safe airway management strategy in the presence of restricted cervical spine mobility

Department of Anaesthesia, General Hospital of Athens ‘G. Gennimatas’, Athens, Greece

Date of Submission27-May-2021
Date of Acceptance26-Jun-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Eleftheria Saoulidou
Kolokotroni 24, Chalandri Athens 15233
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_31_21

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We present a case of extremely difficult airway management in a 56-year-old patient presenting for an elective repair of a recurrent inguinal hernia. He was a diagnosed case of severe ankylosing spondylitis resulting in limited cervical spine mobility and restricted mouth opening. Airway management was achieved with awake nasal intubation and the procedure was completed uneventfully.

Keywords: Ankylosing spondylitis, awake intubation, difficult airway

How to cite this article:
Saoulidou E, Argyriou O, Douma A, Dimakopoulou A. Awake nasal intubation using a videolaryngoscope: A safe airway management strategy in the presence of restricted cervical spine mobility. Airway 2021;4:125-7

How to cite this URL:
Saoulidou E, Argyriou O, Douma A, Dimakopoulou A. Awake nasal intubation using a videolaryngoscope: A safe airway management strategy in the presence of restricted cervical spine mobility. Airway [serial online] 2021 [cited 2021 Dec 2];4:125-7. Available from: https://www.arwy.org/text.asp?2021/4/2/125/323576

  Introduction Top

Ankylosing spondylitis belongs to a group of rheumatic diseases known as autoimmune seronegative spondyloarthropathies.[1] The pathophysiological mechanism involves chronic inflammation of the axial skeleton and surrounding tissue, and patients commonly present with limited spinal activity and lumbar back pain.[2],[3] Sacroiliac joints and lumbar vertebrae are affected primarily, with later involvement of the thoracic and cervical spine, leading to fibrous or bony ankylosis and spinal deformity.[3],[4]

Anaesthetic management in a case of ankylosing spondylitis can be very challenging, particularly with regards to airway management and central neuraxial blockade. Frequently encountered difficulties include limited mouth opening, limited cervical movement and atlantoaxial subluxation, all of which hinder adequate visualisation of the glottis during rigid laryngoscopy.[3],[5] Subsequently, given the limited use of conventional airway management methods in this type of patient, alternative approaches had to be considered.

  Case Report Top

A 56-year-old male with a history of ankylosing spondylitis diagnosed 15 years prior presented for elective repair of a recurrent inguinal hernia. In addition, his medical history included hypertension, asthma and an undefined neuropathy resulting in hemiplegia.

Preoperative airway assessment revealed no jaw protrusion, no cervical flexion or extension, as well as minimal mobility of the cervical and thoracolumbar spine. Mouth opening was <3 cm (modified Mallampati class 4), thyromental distance was <6 cm and sternomental distance was <8 cm. Radiological findings confirmed a 'bamboo spine.' Routine preoperative blood tests and electrocardiogram were normal. The anaesthetic plan, proposed techniques, and further management options for anticipated difficult airway were discussed in detail with the patient and consent was obtained.

The patient was positioned supine with his head and neck supported with pillows. Preoxygenation was performed with 100% oxygen for 3 min. Intraoperative monitoring consisted of a 5-electrode electrocardiogram, noninvasive blood pressure and pulse oximetry. Two peripheral venous accesses were secured. Sedation for performing awake intubation was achieved with a bolus of dexmedetomidine 1 μg/kg administered over 10 min, followed by a continuous infusion of 0.4 μg/kg/h and remifentanil (2 ng/mL) via target-controlled infusion. Lignocaine spray (10%) was used without any other nerve blocks to produce topical airway anaesthesia. Nasotracheal intubation was successfully performed at the first attempt under videolaryngoscopy (C-MAC, D-blade) with a 6.5 mm ID cuffed endotracheal tube. Correct placement of the tube was confirmed by visualisation of the tube passing between the vocal cords, capnographic waveform and bilateral chest auscultation. Induction was performed with ketamine 20 mg, propofol 200 mg, fentanyl 100 μg and rocuronium 80 mg. Anaesthesia was maintained with desflurane in a 50:50 mixture of air: oxygen and patient placed on volume controlled ventilation. Intravenous morphine (5 mg) was used for postoperative analgesia as the surgery was for a recurrent inguinal hernia repair. After an uneventful surgery that took an hour and 30 min, the patient was extubated in the immediate postoperative period.

  Discussion Top

Ankylosing spondylitis is a chronic inflammatory disease, more common in males, with a peak age of onset between 20 and 30 years.[2] It is characterised by painful chronic inflammatory arthritis with exacerbations and quiescent periods. It primarily affects the spine and sacroiliac joints and eventually causes fusion and rigidity of the spine.[6] The uniform development of widespread annular fibrous ossification and the formation of bony bridges (syndesmophytes) are responsible for the 'bamboo spine' radiographic appearance.[4],[6]

The involvement of the cervical spine in ankylosing spondylitis restricts head and neck mobility, which is required not only for visualisation of the glottis during direct laryngoscopy but also for effective mask ventilation.[5] This significantly limits the use of endotracheal intubation when needed.

In these cases, the choice of laryngoscope is very important. The preferred laryngoscope should be slim enough to be introduced through the restricted mouth opening and also be able to provide glottic view with as minimal cervical manipulation as possible.[7] A variety of options are available including blind nasal intubation, lighted stylet-aided intubation, fibreoptic bronchoscope, tracheostomy and videolaryngoscope.[5],[6] Videolaryngoscopy requires less cervical spine extension and has been found to provide better glottic exposure in patients with restricted neck movements.[5]

A thorough preoperative airway assessment is essential for predicting difficulty in tracheal intubation.[3],[8] This includes modified Mallampati class, thyromental and sternomental distances, interincisor gap and atlanto-occipital extension.[8] Awake intubation is the safest option in patients with ankylosing spondylitis as spontaneous breathing and upper airway muscle tone are retained. Spinal and epidural anaesthesia have limited application, due to ossification of the interspinous ligament and formation of bony bridges, leading to a higher complication rate.[3]

Declaration of patient consent

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

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Oliveira CR. Ankylosing spondylitis and anesthesia. Rev Bras Anestesiol 2007;57:214-22.  Back to cited text no. 1
Joshi AP, Sathe V, Madaan D, Sareen D, D'Souza O. Case report of difficult intubation in a patient with ankylosing spondylitis with review of literature. Int J Curr Res 2016;8:38878-81.  Back to cited text no. 2
Jin XY, Zhang H, Wang Q. The use of lidocaine aerosol inhalation in an awake tracheal intubation in an ankylosing spondylitis patient with fiber optic bronchoscopy: A case report. Res Rev J Pharmacol Toxicol Stud 2016;4:31-5.  Back to cited text no. 3
Kotekar N, Nagalakshmi NV, Gururaj, Rehman M. A case of severe ankylosing spondylitis posted for hip replacement surgery. Indian J Anaesth 2007;51:546-9.  Back to cited text no. 4
  [Full text]  
Subedi A, Tripathi M, Bhattarai B, Pokharel K, Dhital D. Successful intubation with McCoy laryngoscope in a patient with ankylosing spondylitis. J Nepal Health Res Counc 2014;12:70-2.  Back to cited text no. 5
Ul Haq MI, Shamim F, Lal S, Shafiq F. Airway management in a patient with severe ankylosing spondylitis causing bamboo spine: Use of aintree intubation catheter. J Coll Physicians Surg Pak 2015;25:900-2.  Back to cited text no. 6
Karne V, Sadavarte N. Airway management in a patient with severe ankylosing spondylitis. Indian J Basic Appl Med Res 2014;3:251-5.  Back to cited text no. 7
Ramanathan G, Jayakar GG, Kuppuswamy A, Ramamurthy B, Patil S. Case study: Managing a case of ankylosing spondylitis for inguinal hernia repair. Southern Afr J Anaesth Analg 2010;16:74-6.  Back to cited text no. 8


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