Managing a difficult airway due to supraglottic masses: successful videolaryngoscopic intubation after induction of general anesthesia

doi:10.21203/rs.3.rs-3337086/v1

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Case Report

Managing a difficult airway due to supraglottic masses: successful videolaryngoscopic intubation after induction of general anesthesia

https://doi.org/10.21203/rs.3.rs-3337086/v1

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published 20 Mar, 2024

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Background

Awake fiberoptic intubation is regarded as the gold standard for managing anticipated difficult airways. However, it may not be feasible in patients with supraglottic masses.

Case presentation

A 41-year-old female patient was scheduled for excision of bilateral, mobile, and pedunculated masses on both aryepiglottic folds, which covered almost the entire upper part of the glottis. Considering her symptoms (neither stridor nor dyspnea in any position) and the risks of awake fiberoptic intubation in this patient (bleeding, damage, and displacement of the masses), the initial decision was to proceed with gentle tracheal intubation using a videolaryngoscope under general anesthesia. Ensuring that mask ventilation was maintained with ease, the patient was sequentially administered intravenous propofol, remifentanil, and rocuronium. Under sufficient depth of anesthesia, intubation using a videolaryngoscope was successfully performed without any complications.

Conclusions

Videolaryngoscopic intubation after induction of general anesthesia can be a feasible alternative for managing difficult airways in patients with supraglottic masses.

Difficult airway management

Videolaryngoscopy

Intubation

General anesthesia

Neuromuscular blockade

Supraglottic masses.

Endotracheal intubation in patients with a supraglottic mass presents a significant challenge for anesthesiologists. The presence of a large supraglottic mass can impede mask ventilation and tracheal intubation, leading to potential difficulties in airway management.[1–3] Therefore, comprehensive preoperative evaluation, preparation, and preplanned strategies are essential for managing anticipated difficult airways.[4]

Awake fiberoptic intubation is regarded as the technique of choice for patients with anticipated difficult airways.[5, 6] However, achieving a smooth and successful process of awake intubation, which includes the application of topical anesthesia and fiberoptic endotracheal intubation, can be particularly challenging in patients with upper airway obstructions.[7] Therefore, the decision to perform awake intubation or manage the airway after induction of general anesthesia should be made on a case-by-case basis by considering the individual risk-benefit ratio.[4] Furthermore, recent studies have reported comparable effectiveness of the videolaryngoscope and fiberoptic bronchoscope for awake tracheal intubation; similar outcomes are achieved in terms of glottic view, laryngeal inlet visualization time, intubation success rate on the first attempt, and intubation time.[8–10]

This case report illustrates a successful intubation process using a videolaryngoscope under general anesthesia in a patient with bilateral, mobile, and pedunculated masses on both aryepiglottic folds.

This case report was approved by the Institutional Review Board of the Chonnam National University Hospital (IRB no. 2023 − 112). A written informed consent for publication was obtained from the patient. A 154-cm, 47-kg, 41-year-old female patient presented to the hospital with hoarseness and difficulty swallowing. These symptoms had persisted for 2 months following a COVID-19 infection. She had no other underlying disease and could perform daily activities without limitations. On clinical examination, she exhibited hoarseness but did not show any signs of stridor or coughing. She had not experienced shortness of breath in any position and was able to take deep breaths. Laryngeal fiberscopic examination revealed the presence of bilateral, mobile, and pedunculated masses on both aryepiglottic folds. These masses partially covered the upper part of the glottis. Computed tomography of the neck revealed a mass 0.8-cm in diameter originating from the right aryepiglottic fold and a mass 1.0-cm in diameter originating from the left aryepiglottic fold (Fig. 1). She was scheduled to undergo laryngeal microsurgery under general anesthesia one month later. However, during the follow-up conducted 2 weeks before surgery, the masses had increased considerably in size, covering almost the entire upper part of the glottis (Fig. 2). Due to the rapid growth rate, the surgery was rescheduled for 2 days later.

A preoperative airway assessment revealed a Mallampati score of 1 with normal mouth-opening and neck movements. Both the ear, nose, and throat (ENT) surgeon and attending anesthesiologist shared a significant concern regarding airway management in this patient, leading to extensive discussions. The main concerns in managing the airway were potential difficulties in mask ventilation and the risk of damage and displacement of the masses during endotracheal intubation. Specifically, their emphasis was on identifying strategies to prevent the masses from being detached and blown into the lower airway during the intubation procedure. This could occur if the topical anesthesia for awake intubation or the process of endotracheal intubation using a fiberoptic bronchoscope was not executed smoothly. If the very narrow stalks of the masses on either side of the aryepiglottic folds were cut off, parts or all of the masses could move past the vocal cords, causing distal airway obstruction. Because the patient had never exhibited stridor or dyspnea in any position and based on the findings from the laryngeal fiberoptic examination, the initial decision was to proceed with a gentle tracheal intubation using a KoMAC videolaryngoscope (KoMAC Co., Ltd., Seoul, Republic of Korea) after induction of general anesthesia with neuromuscular blockade. The patient was informed about the potential risk of undergoing an emergent tracheostomy if mask ventilation or tracheal intubation were not possible during the induction of general anesthesia. The patient understood and consented to undergo any necessary procedures.

The patient was taken to the operating room without premedication. Standard monitoring was initiated. The ENT surgeon was prepared for an emergency tracheostomy in case of insufficient oxygenation or failed tracheal intubation during the induction process. Preoxygenation was conducted using a closed face mask with 100% oxygen delivered at a rate of 8 L/min for more than 5 minutes. The difficulty in achieving manual mask ventilation was assessed using the Han scale for mask ventilation.[11]

The administration of medications was sequential, ensuring that lung ventilation was maintained with ease. An initial dose of 50 mg of 1% propofol was administered, and mask ventilation was assessed (Han grade 1: ventilation by mask without adjuncts). Additionally, a 50 mg dose of 1% propofol was given, resulting in patient unresponsiveness, and ventilation was reassessed (Han grade 1). Subsequently, 40 mg of rocuronium was administered, and successful mask ventilation was confirmed (Han grade 1). The initial rate of remifentanil infusion was 0.1 µg/kg/min, and it was gradually increased to 0.3 µg/kg/min.

When anesthesia was considered to be deep enough to suppress airway reflexes, such as coughing, gagging, and laryngospasm, the KoMAC videolaryngoscope blade was gently inserted into the patient’s mouth. The tip of the blade was carefully positioned in the vallecula, and the glottal opening was visible below the bilateral masses. The structures around the vocal cords, including the masses, were clearly visible to both the attending anesthesiologist and assistant on the videolaryngoscope monitor. A prompt decision was made to proceed with tracheal intubation instead of waking the patient or performing an emergency tracheostomy. It was also decided that tracheal intubation attempts should be limited to a maximum of 1–2 times to minimize the potential for bleeding or damage of the masses. By carefully advancing the tip of a 5.5-mm armored endotracheal tube (ETT) between the bilateral masses towards the glottal opening under continuous video control, successful tracheal intubation was achieved (Fig. 3). We visually confirmed the successful passage of the ETT without significant damage or bleeding of the masses during the procedure. An ETT with a smaller diameter than usual was chosen to reduce the risk of disrupting the masses and to facilitate the smooth passage of the tube into the glottal opening. Anesthesia and airway management took about 10 minutes; throughout this time, oxygenation and hemodynamics remained stable. Anesthesia was maintained with desflurane and remifentanil.

Surgery took place over the next 50 minutes. The ENT surgeon performed a biopsy and excision of the bilateral aryepiglottic fold masses using microscissors. Throughout the operation, the patient's vital signs remained stable, and no notable findings were observed. At the end of the surgery, videolaryngoscopy was used to verify the absence of edema or bleeding at the surgical site. After confirming the patient’s recovery of consciousness and spontaneous breathing, extubation was performed. The patient was transferred to the recovery room and then the ward without any respiratory or hemodynamic complications. Histological examination of the aryepiglottic fold masses revealed they were granulation tissues. The patient was discharged from the hospital 3 days after the operation without complications.

This case report presents our management of a patient with bilateral, mobile, and pedunculated masses on both aryepiglottic folds. The main focus of airway management was to minimize the risk of damage, bleeding, or displacement of the masses. These risks would have increased if the process of awake intubation, which includes topical anesthesia and fiberoptic tracheal intubation, did not proceed smoothly. Therefore, our airway management of this patient may seem to have strayed from the conventional gold standard for difficult airway management. Because the concept of a perceived difficult airway encompasses a wide range of circumstances, an individual approach may be more appropriate to ensure optimal decisions rather than a strict adherence to a uniform difficult airway algorithm.[4]

First, awake intubation was not attempted, although difficult ventilation and intubation were predicted. Instead, tracheal intubation was attempted after induction of general anesthesia, including neuromuscular blockade. Although awake intubation has been cited as the gold standard for management of anticipated difficult airways, it may be prudent to choose between awake and post-induction airway management on a case-by-case basis.[4] In addition, the literature is insufficient to evaluate the benefits or risks of maintenance versus ablation of spontaneous ventilation and the use of neuromuscular blockade to improve mask ventilation.[4] Our assessment was that manual mask ventilation would be maintained after ablation of spontaneous ventilation and administration of neuromuscular blockade for this patient, as there were no signs of stridor or dyspnea in any position including supine position. Instead, concerns were raised about the risk of the patient's hanging masses being blown away due to airway reflexes, such as coughing, gagging, and laryngospasm. This could occur during the application of topical anesthesia for awake intubation or the process of endotracheal intubation using a fiberoptic bronchoscope. It could even occur during post-induction intubation if the depth of general anesthesia was insufficient to suppress airway reflexes. To address this, adequate doses of propofol, remifentanil, and rocuronium were sequentially administered while ensuring that mask ventilation was maintained with ease. When the attending anesthesiologist determined that the patient was sufficiently anesthetized to suppress airway reflexes, a gentle videolaryngoscopy was performed to evaluate the feasibility of intubation.

To ensure the safety of airway management, the induction of general anesthesia was performed in preparation for a difficult mask ventilation and tracheal intubation. Preoxygenation of the patient for more than 5 minutes was conducted, and 16 mg/kg of sugammadex was prepared.[12, 13] Induction of general anesthesia was initiated while the ENT surgeon was on standby, prepared to perform a tracheostomy if needed. We did not consider rigid bronchoscopy by the surgeon due to its associated risks. Specifically, navigation of the rigid bronchoscope tip between the bilateral, mobile, and pedunculated masses into the glottal opening could disrupt the masses, potentially causing some or all of them to be displaced beyond the vocal cords.

Second, intubation was performed with videolaryngoscopy instead of flexible fiberoptic bronchoscopy. Precise manipulation of the flexible tip of the bronchoscope is difficult, especially in the presence of supraglottic masses.[1, 2] In addition, during intubation using a fiberoptic bronchoscope, the tip of the ETT is not visible. Therefore, it would be unclear whether the tumors were being displaced beyond the vocal cords due to the tube insertion. In this case, due to the narrow space between the bilateral masses and the glottal opening, advancing the ETT over the fiberoptic bronchoscope could push the masses into the glottis. This poses a risk for serious complications, such as bronchial obstruction and collapse. Thus, we chose to use a videolaryngoscope instead of a fiberoptic bronchoscope for tracheal intubation. The videolaryngoscope offers better control because the curved blade tip can be manipulated more easily in the desired direction and placed more accurately within the intended anatomical structure.[1] In addition, the videolaryngoscope enables full visualization of the ETT tip on the monitor. As a result, safer and more controlled advancement of the ETT throughout the intubation procedure was possible, preventing the masses from being inadvertently pushed, damaged, or bleeding.

In conclusion, tracheal intubation using a videolaryngoscope after induction of general anesthesia, including neuromuscular blockade, may be feasible in patients with supraglottic masses who do not exhibit stridor or dyspnea. However, the decision must be based on a comprehensive preoperative evaluation and adequate preparation. It is also essential to have prearranged strategies in place to address potential challenges related to inadequate oxygenation and unsuccessful tracheal intubation.

ENT: ear, nose, and throat

ETT: endotracheal tube

Ethics approval and consent to participate

This case report was approved by the Institutional Review Board of the Chonnam National University Hospital (IRB no. 2023-112).

Consent for publication

Written informed consent for publication was obtained from the patient.

Availability of data and materials

The data and materials associated with the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

None

Authors’ contributions

Hye-won Jeong (Conceptualization; Investigation; Writing – original draft)

Eun-Jin Song (Writing – original draft)

Eun-A Jang (Writing – review & editing)

Joungmin Kim (Conceptualization; Investigation; Supervision; Writing – review & editing)

Acknowledgements

None

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No competing interests reported.

Download PDF

Journal Publication

published 20 Mar, 2024

Read the published version in Perioperative Medicine →

Editorial decision: Revision requested
06 Jan, 2024
Reviews received at journal
05 Jan, 2024
Reviewers agreed at journal
02 Jan, 2024
Reviewers invited by journal
29 Dec, 2023
Submission checks completed at journal
11 Sep, 2023
Editor assigned by journal
11 Sep, 2023
First submitted to journal
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You are reading this latest preprint version

Managing a difficult airway due to supraglottic masses: successful videolaryngoscopic intubation after induction of general anesthesia

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