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LETTER TO EDITOR Table of Contents  
Ahead of print publication
Unusual difficult airway view in a patient following corrosive poisoning: Videolaryngoscope replaces fibreoptic-guided intubation


 Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

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Date of Submission06-Aug-2022
Date of Acceptance28-Sep-2022
Date of Web Publication07-Nov-2022
 


How to cite this URL:
Subramanian H, Govindaraj K, Senthilnathan M. Unusual difficult airway view in a patient following corrosive poisoning: Videolaryngoscope replaces fibreoptic-guided intubation. Airway [Epub ahead of print] [cited 2022 Nov 28]. Available from: https://www.arwy.org/preprintarticle.asp?id=360525




Airway management following corrosive acid ingestion is difficult due to fibrosis and subsequent stricture formation distorting the airway.[1] Anaesthesiologists face challenges in securing the airway as airway mishaps are often the cause of anaesthesia-related morbidity and mortality.[2] We present a patient following colopharyngoplasty with decannulated tracheostomy now scheduled for emergency laparotomy. A 25-year-old male with a history of corrosive ingestion and subsequent corrective surgery a year prior presented with volvulus. The patient was stable except for tachycardia. Airway examination was normal except for restriction of terminal neck extension. Preoperative indirect laryngoscopy (IDL) revealed adhered immobile epiglottis and arytenoids with posterior half of the mobile vocal cords visible through an aperture of fibrous bands. With difficult airway cart being kept ready, our plan A was to perform check videolaryngoscopy (VLS) when preserving spontaneous ventilation, administer succinylcholine and perform intubation. Plan B was to perform flexible fibreoptic bronchoscopy-guided intubation in case of difficult visualisation of larynx and plan C was surgical airway access. Written informed consent was obtained for this airway management plan.

Monitoring consisting of electrocardiogram, noninvasive blood pressure and pulse oximeter was established. Glycopyrrolate 0.4 mg was administered intramuscularly. Aspiration prophylaxis was given with intravenous (IV) pantoprazole 40 mg, and prokinetics were avoided as the patient had bowel obstruction. Preoxygenation was done with 100% oxygen and continuous oxygenation was provided through a nasal cannula. After IV fentanyl 80 μg and propofol 100 mg, a check laryngoscopy was done with Niscomed Besdata Videolaryngoscope (Shenzhen, China) using the D-blade as the patient had restriction of neck movements. This revealed a hooded epiglottis plastered to arytenoids and surrounding structures with the fibrotic strands encasing the airway with a hole through which the cords were visualised [Figure 1]a and [Figure 1]b. After ensuring adequate mask ventilation, intubation was attempted following IV succinylcholine. The endotracheal tube was passed through the fibrotic aperture in the first attempt with minimal manipulations. Dexamethasone was administered to reduce glottic oedema and morphine was given for analgesia. Adhesiolysis followed by resection and anastomosis of small bowel was done. The surgery was completed in 5 h without any complication. Extubation was performed under gentle videolaryngoscopic vision to prevent stripping of the fibrotic strands through which the tube was passed.
Figure 1: (a) Check videolaryngoscopy during spontaneous ventilation revealed hooded plastered epiglottis (solid arrow) with a hole bounded by fibrotic supraglottic strands (2 hollow arrows). (b) Through the hole in the fibrotic strand, the glottis could be visualised (solid arrow)

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Preanaesthetic cockpit drill of equipment check is mandatory before starting the case. Although the past history of corrosive ingestion is not of concern in a nonoperative setting, we strongly emphasise a perioperative direct or indirect study of the glottic area to obtain a fair idea of the extent and severity of abnormality of the airway. Although IDL was done by otorhinolaryngology team, fibreoptic airway assessment by the anaesthesiologist before induction or direct scopy after induction and before relaxant administration is always advisable to avoid mishaps. Corrective surgery usually concentrates on gastrointestinal structures with just a handful of patients undergoing serial airway dilatation. Gupta and Verma highlighted that the difficult airway cart should include a rigid bronchoscope as a backup.[3] We had chosen videolaryngoscope as prior indirect laryngoscopy gave us the confidence. Yumul et al. stated that VLS helps in faster visualisation of the vocal cords and results in shorter intubation time.[4] The hallmark of management in these cases includes preservation of spontaneous ventilation until confidence is achieved following check laryngoscopy. Intubation must be done under vision to avoid passage into a 'false track'. We also recommend extubation under vision to avoid trauma. In our case, we wanted to highlight the unusual presentation of the epiglottis with plastered structures along with visualisation of the cords through fibrotic strands. In addition, our plan was designed to avoid injury during intubation and extubation when anticipating a difficult airway.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gangakhedkar GR, Gowani N, Rajan A, Kamble R, Shah P. Airway management in a patient with corrosive poisoning: New tools aid an old problem. Indian J Anaesth 2020;64:75-7.  Back to cited text no. 1
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2.
Mercer SJ, Jones CP, Bridge M, Clitheroe E, Morton B, Groom P, et al. Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma. Br J Anaesth 2016;117 Suppl 1:i49-59.  Back to cited text no. 2
    
3.
Gupta P, Verma S. Unique Presentation of Epiglottis in Corrosive Poisoning: A case report [Internet]. Vol. 12, The Internet Journal of Aneshesiology. Internet Scientific Publishers, LLC; 2007. Available from: http://dx.doi.org/10.5580/26ec. [Last accessed on 2022 Jul 21].  Back to cited text no. 3
    
4.
Yumul R, Elvir-Lazo OL, White PF, Durra O, Ternian A, Tamman R, et al. Comparison of the C-MAC video laryngoscope to a flexible fiberoptic scope for intubation with cervical spine immobilization. J Clin Anesth 2016;31:46-52.  Back to cited text no. 4
    

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Correspondence Address:
Kirthiha Govindaraj,
Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
India
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Source of Support: None, Conflict of Interest: None



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