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From the Anesthesia Service, the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA.
Address correspondence to: Dr. Paul S. Pagel, Clement J. Zablocki Veterans Affairs Medical Center, Anesthesia Service, 5000 W. National Avenue, Milwaukee, Wisconsin 53295, USA. Phone: 414-384-2000, ext. 42417; Fax: 414-384-2939; E-mail: pspagel{at}mcw.edu
Purpose: In this report, we discuss a patient with acute pseudomembranous supraglottitis complicating recurrent tonsillar carcinoma and describe the ramifications of these disorders on perioperative management.
Clinical features: The patient was an acutely ill man with a history of right tonsillar carcinoma originally treated with chemoradiation therapy and a radical neck dissection who presented with a brief history of fever, dyspnea, and stridor. The soft tissue of his neck was very stiff, his neck mobility was limited, and his mouth opening was restricted by pain and radiation-induced fibrosis. A nasal flexible fibreoptic laryngoscopy revealed a very large, indurated epiglottis almost completely obstructing the glottis. The aryepiglottic folds and false cords were edematous, and a gray pseudomembranous exudate was observed on the glottic surface, epiglottis, and true vocal cords. An elective tracheostomy was performed in the operating room using local anesthesia, and conscious sedation was avoided because of the potential for complete airway obstruction. General anesthesia was induced after the airway was secured, but trismus and tissue edema resulting from the acute infection made the glottis and surrounding structures nearly impossible to visualize during direct laryngoscopy. The patient was treated with intravenous antibiotics, and a subsequent direct laryngoscopy demonstrated tumour recurrence.
Conclusions: The case emphasizes that the perioperative management of imminent airway obstruction by acute supraglottitis complicating recurrent oropharyngeal cancer may optimally be approached by establishing a surgical airway under controlled operating conditions.
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