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*Department of Anesthesia and Critical Care, the University of Chicago, Chicago Illinois; Department of Anesthesiology, Northwestern University, Chicago, Illinois, and Department of Otolaryngology and Communication Sciences, Baylor College of Medicine, Houston, Texas
Address correspondence and reprint requests to Andranik Ovassapian, MD, Department of Anesthesia and Critical Care, University of Chicago Hospitals, MC 4028, 5841 S. Maryland Ave., Chicago, IL 60637. Address e-mail to aovassap{at}airway.uchicago.edu.
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Abstract |
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Introduction |
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Tracheostomy using local anesthesia has been considered the "gold standard" of airway management in patients with deep neck infections, but it may be difficult or impossible in advanced cases of infection because of the position needed for tracheostomy or because of anatomical distortion of the anterior neck (1,8). Tracheal intubation using a rigid laryngoscope under general anesthesia, awake blind nasal intubation (BNI), and awake fiberoptic intubation have been reported, but with disappointingly frequent failure (9,10). This article summarizes our experience with fiberoptic intubation using topical anesthesia in 26 patients with deep neck infections.
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Methods |
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Eight patients treated before 1986 were premedicated with IM morphine 5–10 mg and atropine 0.4 mg. Eighteen patients received atropine 0.4 mg or glycopyrrolate 0.2 mg IV 15–30 min before application of topical anesthesia. All patients were given supplemental oxygen through a nasal cannula and had IV line placement. In the operating room after routine monitors were attached, baseline vital signs were recorded. Sedation was begun with IV titration of diazepam or midazolam with or without fentanyl before application of topical anesthesia. The goals of sedation were to have a calm patient able to respond to verbal commands, to depress airway reflexes, and to minimize unpleasant recall. The surgical team was in the operating room ready for emergency cricothyrotomy in case of airway loss.
For nasotracheal intubation, the nasal passage was prepared with 4% cocaine (2–3 mL) or 3% lidocaine and a 0.25% phenylephrine mixture (2–3 mL) by using cotton-tip applicators. For orotracheal intubation, the base of the tongue and the pharyngeal walls were anesthetized with a 10% or 4% lidocaine spray (average, 150 mg). Topical anesthesia of the larynx and trachea was achieved in 13 patients by a spray-as-you-go technique and in 10 patients with translaryngeal injection of 3–4 mL of 4% lidocaine (120–160 mg). If the suction channel of the fiberoptic bronchoscope (FB) was more than 1.5 mm, an epidural catheter was passed through the channel so that a fine spray of local anesthetic could be injected through the catheter (12). In two patients, the planned spray-as-you go technique for topical laryngotracheal anesthesia was not used because airway reflexes were depressed and patients did not react to advancement of the FB. For nasal intubation, the tube-first technique was used, except in four patients with pharyngeal abscesses, in whom the scope-first technique was applied. The endotracheal tube, which was placed in a warm water bath to make it more pliable, was lubricated and passed through the prepared nostril into the pharynx. The FB was passed through the endotracheal tube, the glottis was identified, and the FB, followed by the endotracheal tube, was advanced into the trachea. For orotracheal intubation, an Ovassapian intubating airway was placed, and the lubricated endotracheal tube was positioned inside the airway, followed by the FB. Intubations were attempted in 3 patients in the sitting position, 2 in Fowler’s position, and 21 in the supine head-up (10°–15°) position. Patients were interviewed after surgery about the overall experience and recall of the events.
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Results |
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Tracheal intubations were successful in 25 patients: 19 nasally and 6 orally. In one patient, tracheostomy using local anesthesia was performed because narrow nasal passages prevented the passage of an endotracheal tube.
The specifics of fiberoptic intubation, including the degree of difficulty for vocal cord exposure and intubation times, are summarized in Table 2. Eleven patients were tracheally extubated and cared for in the postanesthesia care unit before discharge to the intensive care unit. Nine patients were kept intubated from 10 h to 5 days. Six patients ultimately required a tracheostomy.
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Ten patients (40%) developed complications: mild epistaxis in three, hypertension and tachycardia in six, cough during intubation in nine, and oversedation and transient hypoxemia (Spo2 <90%) in four. Twelve patients remembered part of the procedure, and two considered it unpleasant. For four patients this information was missing. Loss of airway, the most feared complication, was not encountered.
Two patients with a severely compromised airway presented a special problem. One patient, treated in 1978, developed Ludwig’s angina because of an infected malignant tumor of the tongue complicated with cellulitis, edema, and engorged veins of the anterior neck region. The patient could not open his mouth, and air exchange was possible only in a sitting position leaning to his left side. Because of the patient’s inability to lie down and the distorted anterior neck anatomy, the surgeon requested that the airway be secured before tracheostomy. Intubation was achieved nasally with the patient in the sitting position. Tracheostomy was achieved with difficulty and with 700 mL of blood loss.
In the second patient, treated in 1979, Ludwig’s angina was of odontogenic origin. The patient—who was obese, with a short, thick neck and a mouth opening of <1 cm—could breathe air only in the sitting position. After 30 min of multiple unsuccessful attempts at fiberoptic intubation and a few attempts at BNI, the surgeon was asked to perform tracheostomy under local anesthesia. The surgeon was reluctant to proceed because of the difficulty of positioning the patient and the anticipated technical difficulties of tracheostomy. Topical anesthesia was repeated, and fiberoptic nasotracheal intubation was eventually achieved after another 15 min.
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Discussion |
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Improved dental care and medical management with an antibiotic and dexamethasone in the early stages of the disease have minimized the need for surgical intervention to control the airway (8,9). However, when medical treatment has failed, unrecognized airway obstruction has resulted in severe complications (2,9). In one study of eight patients treated medically, four subsequently required emergency tracheostomy (2).
Tracheostomy using local anesthesia has been considered the gold standard of airway management in patients with deep neck infections (1,3). In a group of 36 patients with Ludwig’s angina, 16 underwent successful elective tracheostomy using local anesthesia; intubation attempts failed in 11 (55%) of the other 20 patients and resulted in acute airway loss that required emergency tracheostomy (5). On the basis of this outcome, elective awake tracheostomy was suggested for all patients with deep neck infections to avoid the dangers associated with emergency tracheostomy (5). Tracheostomy using local anesthesia in patients with a severely compromised airway and distorted anterior neck anatomy can be a nightmare (3,8). In our series, for the two patients with the most advanced cases of the disease, the airway was secured with intubation before tracheostomy, at the surgeon’s request. Tracheostomy also conveys substantial risk of infection spread to the mediastinum (7) and tracheal stenosis as a late complication. Aspiration of pus, rupture of the innominate artery, spread of infection to the thorax, airway loss, and death have been reported (7,14,15).
Tracheal intubation in patients with deep neck infections is challenging. The distorted airway anatomy, tissue immobility, and limited access to the mouth make orotracheal intubation with rigid laryngoscopy difficult (1,6,10,13). In the early stages of the disease, general anesthesia may overcome trismus and allow the mouth to be opened for rigid laryngoscopy (10). One series reported a 90% success rate for tracheal intubations among 10 patients with Ludwig’s angina after the induction of general anesthesia (10). In advanced cases, the induction of general anesthesia is dangerous, because it may precipitate complete airway closure and make face mask ventilation and tracheal intubation impossible, thus necessitating emergency tracheostomy (1,6,13). Rupture of an abscess and aspiration of pus have been reported during an attempted orotracheal intubation under general anesthesia (6,13).
The reported success of awake BNI in patients with upper airway infection is infrequent: two (50%) of four cases in one series (9). BNI is a simple technique with two major drawbacks: infrequent success on the first pass and increased trauma with repeated attempts, precipitating complete airway obstruction that necessitates emergent cricothyrotomy (5,9,14). The first successful fiberoptic nasotracheal intubation in a patient with Ludwig’s angina was reported in 1974 (16); however, subsequent reports of awake fiberoptic nasotracheal intubations were associated with frequent failure: two (66%) of three in one report (9,17).
Tissue edema and immobility, a distorted airway, and copious secretions, common in patients with deep neck infections, contribute to the difficulty of fiberoptic intubation. However, more often, the failure to intubate is caused by inadequate preparation of the patient, use of a poor-quality FB, and inadequate experience with the procedure (9,18–20). In our series, all 25 attempted intubations were successful without major complications. The success is attributed to a well organized approach to awake intubation and expertise in flexible bronchoscopy. Avoiding airway irritation and laryngeal spasm is critical to prevent sudden airway loss (18,19). Application of topical anesthesia before sedation is unpleasant to the patient and precipitates cough and laryngeal spasm (19). Instrumentation of the airway with poor topical anesthesia also precipitates laryngeal spasm and airway loss. Our experience with 3000 tracheal intubations using topical anesthesia during the past 26 years has convinced us that narcotic-induced depression of the airway reflexes complements the topical anesthesia produced by local anesthetic. Two patients in this series were tracheally intubated without application of topical anesthesia to the larynx and trachea, and we attribute this to the profound effect of fentanyl on airway reflexes. The combination of midazolam and fentanyl increases the risk of respiratory depression (21); therefore, these drugs must be titrated carefully.
An anesthesiologist well trained in awake fiberoptic intubation can intubate most patients with deep neck infections smoothly, expeditiously, and with minimal discomfort to the patient. The FB does not induce pain, can be applied through oral or nasal routes, and can be used in any position comfortable to the patient. Topical anesthesia of the larynx and trachea can be achieved with the spray-as-you-go technique. The topical anesthesia of the larynx is achieved within 1 minute after lidocaine spray followed by tracheal intubation. The patient is at risk for aspiration if regurgitation or vomiting takes place after topical anesthesia and before the airway is secured. A shorter time interval between application of topical anesthesia and tracheal intubation lessens the potential of aspiration (22).
Awake fiberoptic intubation has been recommended for airway management in patients with an airway compromised by infections and tumors (8,12,23). Others have challenged the value of awake fiberoptic intubation in patients with upper airway tumors associated with stridor (20). This report confirms that, in experienced hands, awake fiberoptic intubation can be performed safely in patients with a compromised airway.
The shortcomings of this study are threefold. First, all patients with deep neck infections treated in two hospitals during the study period were not included; only patients with advanced disease for whom the senior author was the anesthesiologist or consultant were included. Second, most cases in this group represent an advanced form of the disease and, therefore, more complicated airways. Third, delayed complications were not known because of the lack of long-term follow-up.
In summary, death from loss of an airway still occurs in patients with advanced deep neck infections. Securing such an airway is challenging and dangerous. Sound clinical judgment is critical for timing and for selecting the method for airway intervention. Tracheostomy using local anesthesia is safe in most patients but is impractical or risky in others. On the basis of our experience, we suggest fiberoptic intubation using topical anesthesia as the first choice for airway control in adult patients with deep neck infections. Tracheotomy under local anesthesia is a good choice if an FB is not available, if the clinician is not skilled with awake fiberoptic intubation, or if attempts at intubation have failed.
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Footnotes |
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References |
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This article has been cited by other articles:
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  A. Dabbagh, N. Mobasseri, H. Elyasi, B. Gharaei, M. Fathololumi, M. Ghasemi, and I. B. Chamkhale A Rapidly Enlarging Neck Mass: The Role of the Sitting Position in Fiberoptic Bronchoscopy for Difficult Intubation Anesth. Analg., November 1, 2008; 107(5): 1627 - 1629. [Abstract] [Full Text] [PDF]
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