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From the Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
Address correspondence to: Dr. David T. Wong, Department of Anesthesiology, Toronto Western Hospital, 399 Bathurst Street, MC 2-405, Toronto, Ontario M5T 2S8, Canada. Phone: 416-603-5118; Fax: 416-603-6494; E-mail: david.wong{at}uhn.on.ca
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Abstract |
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Clinical features: A 49-yr-old man underwent clipping of a left posterior inferior cerebellar artery aneurysm and his tracheal tube was removed postoperatively. Two hours later, he became dyspneic and developed significant macroglossia. After application of topical anesthesia, direct laryngoscopy, oral fibreoptic bronchoscopy and laryngeal mask insertion were unsuccessful. The patient became progressively hypoxemic, pulseless electrical activity ensued, and cardiopulmonary resuscitation was initiated. An uncuffed percutaneous cricothyroidotomy tube was inserted. Oxygenation and hemodynamics were restored. As the cricothyroidotomy tube was uncuffed, there was a large supraglottic leak with manual ventilation. A laryngeal mask airway was inserted and the cuff was inflated. The 15-mm connector was occluded by a piece of tape. Subsequently, there was no further supraglottic leak with manual ventilation. He was taken to operating room and a surgical tracheotomy was performed.
Conclusion: In a patient with postoperative macroglossia in a ‘cannot intubate-cannot ventilate’ situation, effective oxygenation was restored by insertion of an uncuffed cricothyroidotomy, but ventilation was affected by a substantial supraglottic leak. A new strategy using an inflated laryngeal mask airway with an occluded connector was utilized to successfully terminate the supraglottic leak, thereby restoring effective lung ventilation.
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Introduction |
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Case report |
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The next day, the patient underwent clipping of the aneurysm under general anesthesia in the prone position. Tracheal tube insertion was uneventful. The head was positioned in a Sugita frame and a bite block was placed between his teeth. The surgery lasted 11 hr. The estimated blood loss was 200 mL. The endotracheal tube was removed in the operating room, and he was transferred to the neurosurgical intensive care unit (ICU) with a Glasgow coma scale of 15.
Two hours postoperatively, the patient became dyspneic. His SpO2 decreased to 94% and respiratory rate was 30 min–1. Anesthesiology was urgently consulted. At this time, macroglossia with tongue protrusion beyond the lips was observed with no associated lip or facial swelling. The oral-pharyngeal mucosa was topicalized by blindly inserting a 1% lidocaine spray nozzle into the oral cavity. Direct laryngoscopy with a #3 MacIntosh blade was unsuccessful. Oral fibreoptic bronchoscopy was attempted with no visualization of the epiglottis or larynx, and insertion of a size 4 laryngeal mask airway was unsuccessful. While attempting nasal fibreoptic bronchoscopy, the patient’s SpO2 decreased to 50%, pulseless electrical activity ensued and cardiopulmonary resuscitation was initiated. As there were no experienced surgeons in the ICU, the anesthesiologist proceeded to insert a percutaneous dilatational cricothyroidotomy (C-TCCS-600; Cook Inc., Bloomington, IN, USA) with a 6-mm internal diameter uncuffed tube. One minute following cricothyroidotomy insertion and manual ventilation, SpO2 increased to 92% and the patient regained a systolic blood pressure of 120. Cardiopulmonary resuscitation was terminated and the total duration of cardiopulmonary resuscitation was five minutes. Arterial blood gas showed pH 7.38, PCO2 51 mmHg, PO2 108 mmHg.
As the cricothyroidotomy tube was uncuffed, there was a large supraglottic leak with manual ventilation. In an attempt to eliminate the supraglottic leak, a size 4 laryngeal mask airway was inserted into the oral pharynx and the cuff was inflated with 20 mL of air. The 15-mm connector of the laryngeal mask airway was occluded by a piece of tape. Subsequently, there was no further supraglottic leak with manual ventilation. He was taken to the operating room and a surgical tracheotomy was performed.
The patient’s neurologic status improved. The tracheostomy was subsequently downsized and was removed 35 days postoperatively. While in hospital, he was assessed by an allergist. A diagnosis of postoperative tongue angiodema was made. However, latex and penicillin skin testing, and the workup for C1 esterase inhibitor, were negative.
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Discussion |
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The patient developed significant macroglossia two hours postoperatively resulting in acute upper airway obstruction. The differential diagnosis of acute macroglossia includes trauma, infection, superior vena cava syndrome, venous obstruction, lymphatic obstruction, circulatory overload, anaphylaxis, C1 esterase inhibitor deficiency, and post-ischemic hyperemia.10–14 There was no obvious trauma with tracheal tube insertion, and no infection was identified locally or in blood cultures. Lack of head, lip and generalized edema made superior vena cava syndrome, venous obstruction, and circulatory overload unlikely. Skin testing and immunoassay did not reveal any offending agents or evidence of C1 esterase inhibitor deficiency.
We believe the most likely explanation was the occurrence of tongue ischemia during prolonged surgery in the presence of a combination of factors, including the bite block pushing the tongue posteriorly, the presence of the endotracheal tube in a fixed limited oral cavity, and the head fixated in a flexed position with the patient in a prone position.14 Postoperatively, tongue ischemia was relieved, resulting in post-ischemic reperfusion hyperemia and capillary leak leading to acute tongue edema, macroglossia and upper airway obstruction.10–12
Once the percutaneous cricothyroidotomy was successfully inserted, effective ventilation was limited by the presence of a large supraglottic leak with manual ventilation. The management options at that time included accepting the leak, transtracheal jet ventilation via the cricothyroidotomy15 and use of saline soaked oral-pharyngeal gauze packing to minimize supraglottic leak. A new strategy using an inflated laryngeal mask airway with an occluded connector was utilized to successfully terminate the supraglottic leak, thereby enabling the restoration of effective lung ventilation. The combined use of cricothyroidotomy and a laryngeal mask airway in a CICV situation has not been reported elsewhere. There exist a number of newer supraglottic airway devices such as the Laryngeal Tube®, CobraPLA®, Intubating Laryngeal AirwayTM, and SLIPATM which may be utilized to achieve the same goal as the laryngeal mask airway to prevent a supraglottic leak. However, the laryngeal mask airway is currently the most ubiquitous and readily available supraglottic airway, key factors for its utilization in this case. Several of the newer cricothyroidotomy sets also have cuffed cricothyroidotomy tubes, which would most likely have eliminated the supraglottic leak encountered in our patient. However, the conventional uncuffed cricothyroidotomy sets are still utilized by many health care institutions.
In summary, a patient developed acute postoperative macroglossia, upper airway obstruction and an emergent life threatening CICV situation following prolonged surgery in the prone position. Effective oxygenation was restored by insertion of an uncuffed cricothyroidotomy, but ventilation was impaired by a substantial supraglottic leak. A new strategy using an inflated laryngeal mask airway with an occluded connector was utilized to successfully terminate the supraglottic leak, thereby enabling the restoration of effective lung ventilation.
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Footnotes |
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Accepted for publication October 2, 2006. Revision accepted November 9, 2006.
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References |
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2 Wong DT, Lai K, Chung FF, Ho RY. Cannot intubate-cannot ventilate and difficult intubation strategies: results of a Canadian national survey. Anesth Analg 2005; 100: 1439–46.
3 Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991; 75: 1087–110.[Medline]
4 Parmet JL, Colonna-Romano P, Horrow JC, Miller F, Gonzales J, Rosenberg H. The laryngeal mask airway reliably provides rescue ventilation in cases of unanticipated difficult tracheal intubation along with difficult mask ventilation. Anesth Analg 1998; 87: 661–5.
5 Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology 1996; 84: 686–99.[Medline]
6 American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98: 1269–77.[Medline]
7 Henderson JJ, Popat MT, Latto IP, Pearce AC; Difficult Airway Society. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: 675–94.[Medline]
8 Crosby ET, Cooper RM, Douglas MJ, et al. The unanticipated difficult airway with recommendations for management. Can J Anaesth 1998; 45: 757–76.
9 Jenkins K, Wong DT, Correa R. Management choices for the difficult airway by anesthesiologists in Canada. Can J Anesth 2002; 49: 850–6.
10 Denneny JC III. Postoperative macroglossia causing airway obstruction. Int J Pediatr Otorhinolaryngol 1985; 9: 189–94.[Medline]
11 Sinha A, Agarwal A, Gaur A, Pandey CK. Oropharyngeal swelling and macroglossia after cervical surgery in the prone position. J Neurosurg Anesthesiol 2001; 13: 237–9.[Medline]
12 Kuhnert SM, Faust RJ, Berge KH, Piepgras DG. Postoperative macroglossia: report of a case with rapid resolution after extubation of trachea. Anesth Analg 1999; 88: 220–3.
13 Murthy P, Laing MR. Macroglossia. BMJ 1994; 309: 1386–7.
14 Miller RD. Miller’s Anesthesia, 6th ed. Philadelphia, Elsevier Churchill Livingstone, 2005: 2137.
15 Hess DR, Gillette MA. Tracheal gas insufflation and related techniques to introduce gas flow into the trachea. Respir Care 2001; 46: 119–29.[Medline]
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