Anaesthesia for otorhinolaryngological procedures has always been challenging in view of a shared and often difficult airway. A 55-year-old male, a known case of carcinoma right maxilla, presented to us following right total maxillectomy, bilateral anterior and posterior ethmoidectomy, sphenoidectomy and right supraomohyoid neck dissection. He needed a revision maxillectomy in view of a residual lesion predominantly in the right superior nasal cavity and maxillary sinus. Mouth opening was restricted to 1.5 cm making direct laryngoscopy impossible. The mass in the right nasal cavity had eroded and caused deviation of the nasal septum completely towards the left, making nasal fibrescopy also difficult. We successfully managed the airway using the technique of asleep oral fibreoptic-guided intubation.
Keywords: Difficult airway post-radical maxillectomy, facial reconstruction, oral fibreoptic intubation
| Introduction|| |
Anatomical characteristics of the airway contribute to a substantial proportion of cases of difficult intubation. Inability to manage a difficult airway has been responsible for as many as 30% of total deaths attributable to anaesthesia. Management of the airway in a patient with prior extensive facial resection surgery and severely distorted upper airway anatomy may pose a challenge to the anaesthesiologist. A significant number of patients present for elective or emergency procedures after primary facial surgery. Hence, familiarity with a variety of airway equipment and techniques, and their appropriate selection, are important for better patient management and outcome.
| Case Report|| |
A 55-year-old man weighing 70 kg presented to the hospital with pain and numbness in the right maxillary region. The patient diagnosed with carcinoma right maxilla stage IV presented to us on this occasion following right total maxillectomy, bilateral anterior and posterior ethmoidectomy, sphenoidectomy and right supraomohyoid neck dissection. Videolaryngoscope-guided oral intubation was performed on the first occasion and a tracheostomy was performed at the end of surgery in view of the grossly distorted airway anatomy following surgery. As the intraoperative and postoperative periods were uneventful, the patient was discharged 2 weeks later after planned decannulation and tracheostomy closure. The patient later underwent adjuvant chemotherapy and radiotherapy. A magnetic resonance imaging study done before commencing adjuvant therapy revealed residual lesion predominantly in the right superior nasal cavity/maxillary sinus along with the inferomedial aspect of the right orbit. The patient was posted for a revision maxillectomy.
Preanaesthetic evaluation revealed the patient to be a diabetic for 20 years on oral hypoglycaemic agents and insulin with no other comorbidities. Effort tolerance showed METs >4. General physical examination and systemic examination were within normal limits. Veins were accessible and the spine was midline. Airway examination revealed a distorted facial anatomy. Mouth opening was restricted to 1.5 cm and thyromental distance was 6 cm. The temporomandibular joint could not be subluxated. Neck movements were adequate. Preoperative investigations were within normal limits. On examination, the patient was anxious. Despite adequate counselling, the patient was reluctant for any awake intervention. Hence, asleep fibreoptic nasal intubation through the left nostril was planned.
On the day of surgery, the patient was shifted to the operation theatre. Monitoring consisting of electrocardiogram, noninvasive blood pressure and pulse oximetry was initiated and baseline vital signs were noted. An 18 SWG cannula was secured and intravenous (IV) glycopyrrolate 0.2 mg was administered as an antisialagogue. Oxymetazoline drops were administered in the left nostril. Nasal prongs were used to administer oxygen at 15 L/min and a difficult airway cart was checked and kept ready in the operation theatre.
The patient was preoxygenated to target an end-tidal oxygen concentration of >90%. IV fentanyl 2 μg/kg was administered and 4% sevoflurane in 100% oxygen (8 L/min) was started through a face mask connected to a circle system. The patient was kept breathing spontaneously till loss of response to verbal commands was achieved. A tongue stitch was then placed by the otorhinolaryngologist while the face mask was momentarily removed. This was done to overcome airway obstruction caused by the tongue falling back because restricted mouth opening had made insertion of an oropharyngeal airway impossible. During the period of taking tongue stitch, we continued passive oxygenation at 15 L/min through nasal prongs.
Once adequate haemostasis was achieved, a fibreoptic scope preloaded with a 7 mm cuffed endotracheal tube was inserted nasally. However, the fibreoptic scope could not be passed beyond 4 cm. We concluded in discussion with the otorhinolaryngologist that the mass in the right nostril had pushed the nasal septum to the left. We requested the otorhinolaryngologist to standby for a tracheostomy and proceeded to perform an asleep oral fibreoptic intubation.
The anaesthetic depth was increased using titrated doses of IV propofol and 6% sevoflurane in 100% oxygen. Bag mask ventilation was attempted but due to distorted anatomy, it was possible only using a two-handed two-person technique. Check scopy was not possible in view of restricted mouth opening. Bag mask ventilation was continued for 2–3 min. A fibreoptic scope preloaded with a 7 mm internal diameter cuffed endotracheal tube was then introduced orally and a good glottic view was obtained in the first attempt. Despite clear visualisation of the carina, the tube kept hinging at some anatomical structure when advancement was attempted. The tube was withdrawn a few millimetres, rotated 90° anticlockwise and successfully inserted with the final placement being done under fibrescopic vision. The cuff was inflated, bilateral air entry was confirmed and a capnographic waveform was obtained before connecting the ventilator.
Anaesthesia was maintained with 1%–1.5% isoflurane in 50% nitrous oxide in oxygen and IV vecuronium was given for neuromuscular blockade. Analgesia was supplemented with IV morphine and paracetamol. The intraoperative period was uneventful. At the end of the surgery, residual neuromuscular blockade was antagonised using neostigmine with glycopyrrolate. A thorough oral and endotracheal suctioning was done and the patient shifted to postoperative intensive care unit with endotracheal tube in situ in view of anticipated airway oedema. Extubation was planned after overnight observation and monitoring. Morphine infusion was started for pain relief and sedation. IV dexamethasone 8th hourly was started to reduce airway oedema. The patient was nursed in the head-up position overnight and shifted to the operation theatre the next morning. A fibreoptic scope was passed orally alongside the endotracheal tube to exclude any clots or collection of blood in the oral cavity and pharynx. After thorough suctioning, the patient was extubated over an airway exchange catheter. The tongue stitch was removed subsequently.
| Discussion|| |
Formulating an algorithm-based plan for airway management and discussing it with the anaesthesia and surgical team helps alleviate anxiety, instils confidence in the team and avoids unnecessary panic and mismanagement. Awake intubation was precluded due to patient refusal. Nasal intubation planned initially was not possible due to occlusion of both nostrils. Hence, we planned oral fibreoptic-guided intubation after induction of general anaesthesia. A combination of inhalational and IV anaesthesia was used. Had bag-mask ventilation failed, we would still not have burned our bridges as we could have woken up the patient. With some difficulty, bag-mask ventilation was possible and oral fibreoptic-guided intubation was successful. Our otorhinolaryngology colleagues were available for tracheostomy under general anaesthesia with bag-mask ventilation had two attempts at intubation failed. Restricted mouth opening made insertion of an Ovassapian airway impossible. Hence, a tongue stitch was taken to prevent tongue fall after induction of anaesthesia. We would like to emphasise the utility of continuous oxygenation through nasal prongs at 15 L/min for providing apnoeic oxygenation.
Fibreoptic-guided tracheal intubation is accepted as the gold standard in cases of suspected difficult intubation. However, up to 13% failure rate has been reported in literature, mostly due to the inability to pass the endotracheal tube over the fibrescope into the trachea. Once the fibrescope enters the trachea, railroading the endotracheal tube is a blind procedure. Resistance to the passage of the ETT has been reported to range from 5% to almost 90%. Anaesthesiologists performing fibreoptic-guided intubation must be aware of various anatomical locations at which the endotracheal tube can hinge, and know the necessary corrective manoeuvres to guide the tube into the trachea. Failure occurs more frequently during oral intubation and is related to impingement of the tube onto the epiglottis, aryepiglottic folds or corniculate cartilages. We can overcome such a problem by rotating the tube 90° anticlockwise such that the bevel faces down. This manoeuvre helped us manipulate the endotracheal tube into the trachea in the first attempt itself. This problem can be further aggravated in awake intubation due to retention of spontaneous breathing or patient moving the head.
If unable to ventilate, our plan was to wake up the patient and counsel him once again for awake fibreoptic oral intubation or go ahead with tracheostomy under local anaesthesia. We would also like to emphasise that one should have a high index of suspicion for a deviated nasal septum in such cases despite the patient not giving any complaints of nasal block or headaches.
| Conclusion|| |
A meticulous and organised airway management strategy is the key to the successful management of a difficult airway. A back-up plan and good teamwork prevent an avoidable catastrophe.
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 identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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