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* From the Departments of Anesthesia, Nippon Steel Yawata Memorial Hospital,
the Moji Rosai Hospital, and
the Emergency Life Saving Technique Academy, Kitakyushu, Japan.
Address correspondence to: Dr. Ichiro Takenaka, Department of Anesthesia, Nippon Steel Yawata Memorial Hospital, 1-1-1 Harunomachi, Yahatahigashi-ku, Kitakyushu 805-8508, Japan. Phone: 81-93-671-9420; Fax: 81-93-671-9605; E-mail: itaken{at}d4.dion.ne.jp
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Abstract |
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Clinical features: A 61-yr-old man with a known history of difficult laryngoscopic intubation underwent laryngeal microsurgery for recurrence of a glottic tumour. As preoperative indirect laryngoscopy revealed a large, mobile, and pedunculated glottic lesion obstructing the glottic opening, we planned a conventional awake fibreoptic intubation. Endoscopy showed that the tumour partially obstructed the glottis and the space between the tumour and the glottic opening was very narrow. To avoid damage to the tumour, we changed to an alternative fibreoptic intubation technique. The FOB attached to a video camera was passed nasally and a jaw thrust manoeuver was applied, providing an excellent view of the larynx. An anesthesiologist inserted the ETT with a curved stylet orally, and carefully advanced the tube tip into the space between the tumour and the glottic opening under video control. Absence of damage to the tumour and passage of the tube between the cords were confirmed visually.
Conclusion: This alternative intubation technique, providing a view of the tube passage into the glottis, was a reasonable method to avoid potential damage to the glottic tumour by blind tube passage during conventional fibreoptic intubation.
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Case report |
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The patient was premedicated with 0.5 mg atropine im. In the operating room, standard noninvasive monitors, including electrocardiography, indirect arterial pressure, pulse oximetry, and capnography, were applied and the patient received 2.5 mg midazolam iv. Topical anesthesia of the oropharynx was achieved using commercially available 8% lidocaine spray. A superior laryngeal nerve block was performed with 2 mL of 1% lidocaine and the block was repeated on the opposite side. An Ovassapian intubating airway was then inserted into the mouth. The anesthesiologist inserted a 4.9 mm FOB (BF-P30, Olympus, Tokyo, Japan), passed into a 6.0-mm internal diameter microlaryngeal tube (Mallinckrodt, Athlone, Ireland), through the intubating airway into the oropharynx. Supplemental oxygen was insufflated via the working channel. Endoscopy showed that a large glottic tumour partially obstructed the glottis. Because the space between the tumour and the glottic opening was very narrow, we considered that the ETT advancing over the FOB could push the tumour into the glottis or damage it. So, we changed from a conventional fibreoptic technique to an alternative technique described previously (Figure
).6 After the intubating airway was removed and the nostril was anesthetized with long cotton-tipped applicators soaked in 4% lidocaine, a nasopharyngeal airway was inserted. An assistant passed the FOB attached to a video camera (OTV-S5 Olympus) through the nasopharyngeal airway and performed a jaw thrust manoeuver. This provided an excellent view of the larynx which was displayed on the monitor screen. The anesthesiologist inserted a 6.0-mm internal diameter cuffed reinforced tube with a stylet in the "hockey stick" configuration into the oropharynx, and carefully advanced the ETT tip into the space between the tumour and the glottic opening under video control. Absence of damage to the tumour and passage of the ETT between the cords were confirmed visually. Successful intubation was confirmed further by capnography and anesthesia induced with propofol iv. Oxygen saturation did not decrease below 94% throughout intubation. The glottic tumour was removed surgically and the trachea was extubated uneventfully. Pathology confirmed recurrence of the glottic carcinoma. Two weeks later, the patient underwent a total laryngectomy.
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Discussion |
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Conventional laryngoscopy enables to see the advancement of the ETT under direct vision when a full view of the glottis is obtained. In some patients, direct laryngoscopy cannot provide a full view. Many intubation techniques have been devised for such patients,3,4 but few allow a view of the ETT advancement throughout intubation. Even with conventional fibreoptic intubation, advancement of the ETT over the FOB is blind5,6 and may impact on a large tumour.5 Alternative laryngoscopes, such as the Bullard laryngoscope, the Wuscope, and the Upsherscope, allow visualization of ETT advancement.8 With these laryngoscopes, the viewing end of the fibreoptic bundles and the ETT are moved simultaneously, so it may be difficult to obtain a clear view while controlling the ETT tip, especially when the larynx is distorted and obstructed by a large tumour. In contrast, our technique has some useful features. First, with our technique both the operator and assistants can view the glottis and the ETT tip, and therefore the operator can receive assistance while introducing the ETT into the glottis. Second, our technique allows free selection of intubating introducers, including a stylet, a bougie, and a fibrescope, as occasion demands. In our patient, using a stylet, the ETT could be introduced easily through the narrow laryngeal aperture into the trachea. When difficulty in inserting the ETT with the stylet is encountered, forceful advancement should be avoided. Use of a second FOB as an intubating introducer may be useful in this situation.6 Finally, view of the glottis via the FOB is not obstructed by manipulation of the ETT into the trachea because our technique allows the FOB and the ETT to be controlled independently. The excellent view obtained helps advance the ETT while avoiding impact on the tumour. A disadvantage of the technique is the necessity to use the nasal route.
In our patient, application of the jaw thrust manoeuver provided a clear fibreoptic view of the glottis and sufficient room to control the ETT by lifting the tongue, the epiglottis and laryngeal soft tissues.9 We did not use a laryngoscope for these purposes because, in some patients with a difficult airway, the laryngoscope cannot lift the epiglottis from the posterior pharyngeal wall sufficiently, expand structures around the glottis, and provide a good fibreoptic view of the glottis.10 Topical anesthesia of the airway and conscious sedation with midazolam allowed the successful execution of awake intubation. Adequate topical airway anesthesia suppressed gag and cough reflexes, and was essential to obtain an excellent fibreoptic view and to advance the ETT safely. Sedation should be titrated carefully to avoid exacerbation of airway obstruction caused by loss of muscle tone in patients with large laryngeal tumours.
In summary, this case of known, anatomically difficult intubation had the potential for complications during blind passage of the ETT during conventional fibreoptic intubation. An alternative intubation technique, combining the FOB-video camera system and a styletted ETT, permitted an excellent view of the ETT passage into the glottis. We believe this is a reasonable method to prevent problems associated with a large laryngeal tumour in patients with a difficult airway.
Revision received November 16, 2001. Accepted for publication September 5, 2001.
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2 Donlon JV Jr. Anesthetic and airway management of laryngoscopy and bronchoscopy. In: Benumof JL (Ed.). Airway Management Principles and Practice, 1st ed., St. Louis: Mosby, 1995: 666–85.
3 Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991; 75: 1087–110.[Medline]
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Morris IR. Fibreoptic intubation. Can J Anaesth 1994; 41: 996–1008.
5 Ovassapian A. Fiberoptic Endoscopy and the Difficult Airway, 2nd ed. Philadelphia: Lippincott-Raven Publishers, 1996.
6
Aoyama K, Takenaka I, Sata T, Shigematsu A. Use of the fibrescope-video camera system for difficult tracheal intubation. Br J Anaesth 1996; 77: 662–4.
7 Thawley SE. Cysts and tumors of the larynx. In: Paparella MM, Shumrick DA, Gluckman JL, Meyerhoff WL (Eds.) Otolaryngology, 3rd ed. Philadelphia: WB Saunders Co., 1991; 2307–69.
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Cooper SD, Benumof JL, Ozaki GT. Evaluation of the Bullard laryngoscope using the new intubating stylet: comparison with conventional laryngoscopy. Anesth Analg 1994; 79: 965–70.
9
Aoyama K, Takaneka I, Nagaoka E, Kadoya T. Jaw thrust maneuver for endotracheal intubation using a fiberoptic stylet (Letter). Anesth Analg 2000; 90: 1457–8.
10
Takenaka I, Aoyama K, Kadoya T, Sata T, Shigematsu A. Fibreoptic assessment of laryngeal aperture in patients with difficult laryngoscopy. Can J Anesth 1999; 46: 226–31.
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