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PATIENT SAFETY

Failed Tracheal Intubation with the LMA-CTrach^TM in Two Patients with Lingual Tonsil Hyperplasia

From the Anesthesiology Department, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain.

Address correspondence and reprint requests to Ana M. López, MD, PhD, Anesthesiology Department, Hospital Clínic of Barcelona, Villarroel 170, 08036 Barcelona, Spain. Address e-mail to analopez{at}clinic.ub.es.

Abstract

The LMA-CTrach^TM combines the features of the Intubating Laryngeal Mask Airway^TM with a fiberoptic system and a screen for visualization of the airway. Local pathology, such as lingual tonsillar hyperplasia, may obstruct the view of the airway leading to unanticipated difficult intubation. We present two cases of failed intubation with the LMA-CTrach in patients with lingual tonsillar hyperplasia. In both cases, the LMA-CTrach maintained adequate ventilation, giving time to prepare alternative strategies.

The LMA-CTrach^TM (The Laryngeal Mask company, Ltd., Le Rocher, Seychelles) is a new laryngeal mask that combines the features of the Intubating Laryngeal Mask Airway (ILMA)^TM (The Laryngeal Mask company Ltd., UK) with a fiberoptic system and a detachable LCD screen. The device allows direct viewing of the airway and observation of the endotracheal tube as it is advanced through the vocal cords.1,2 Previous studies have demonstrated its utility in managing patients with difficult airways.3–5

Lingual tonsillar hyperplasia is a recognized cause of unanticipated difficult intubation.6–9 We present two cases of failed intubation with the CTrach in patients with lingual tonsillar hyperplasia.

CASE DESCRIPTION

Case 1
A 74-yr-old obese man (weight 90 kg, height 1.70 m, body mass index [BMI] 31 kg/m²) was scheduled for nasal melanoma excision. His surgical history included tonsillectomy in his childhood and cholecystectomy. He had no history of difficult intubation. Clinical examination did not suggest a difficult airway. After induction of anesthesia, a size 4 CTrach was inserted (size 5 CTrach was not available at that time), the patient’s lungs were adequately ventilated, and the screen attached. Supraglottic pale papillomatous tissue was observed, which displaced the epiglottis backwards against the base of the glottis, obscuring the vocal cords. Adjustment maneuvers, including deeper insertion, the "Chandy maneuver" (elevating the CTrach handle to lift the cuff), and the "up–down maneuver" (partial withdrawal and reinsertion with the cuff inflated) did not improve the view.

Three intubation attempts with a dedicated tube (Disposable LMA Fastrach ETT^TM) failed, since the epiglottic bar could not lift the epiglottis and the endotracheal tube was repeatedly directed into the supraglottic space. The CTrach was withdrawn, a size 5 ILMA^TM was inserted, and the lungs were easily ventilated. A 5-mm Olympus LF-T fiberoptic bronchoscope (Olympus Corporation, Tokyo, Japan) was placed to guide intubation. Again the epiglottis was retroflexed beyond the end of the elevating bar. After two brief intubation attempts failed, the ILMA was removed. Tracheal intubation was achieved with a fiberoptic bronchoscope via a Williams airway. At the end of the surgery, the trachea was uneventfully extubated. One week later, an ear–nose–throat endoscopist confirmed the diagnosis of lingual tonsillar hyperplasia.

Case 2
A 49-yr-old obese woman (weight 123 kg, height 1.68 m, BMI 43.6 kg/m²), with a history of adenoidectomy in childhood, presented for resection of a right shoulder melanoma. Preoperative assessment revealed thick and short neck, Mallampati class III airway, thyromental distance of 5 cm, and macroglosia. Information about a potentially difficult airway was given to the patient, who consented to awake intubation with the CTrach. The patient received sedation with midazolam and remifentanil and oxygen through a nasal cannula. Topical anesthesia was applied to the oropharyngeal mucosa.

A size 5 CTrach was selected based on the weight of the patient. The mask was gently inserted, inflated, and connected to the breathing circuit. The display was attached, revealing a large papillomatous tissue in the vallecula, with a large downfolding epiglottis (Fig. 1). All correcting maneuvers previously described, including external displacement of the larynx and jaw, failed to improve the view. Two milliliter of lidocaine 2% was topically administered over the epiglottis with a thin catheter placed down the CTrach lumen. Repeated attempts to lift the epiglottis with a #7.5 endotracheal tube (disposable LMA Fastrach ETT) failed. The epiglottis could not be raised as it lay distal to the edge of the elevating bar. The CTrach was removed and the trachea was intubated with the aid of a fiberoptic bronchoscope. The day after the procedure, an ear–nose–throat endoscopist confirmed the diagnosis of lingual tonsillar hyperplasia.

View larger version (66K): [in this window] [in a new window]   Figure 1. CTrachTM views of the lingual tonsillar hyperplasia in case 2.

DISCUSSION

Lingual tonsillar hyperplasia may cause unanticipated difficult ventilation and intubation.6–9 Ovassapian et al. reported a series of 33 patients with unanticipated difficult intubation in which lingual tonsillar hyperplasia was the only common finding.6 The LMA has been successfully used as a rescue airway device after failed intubation in patients with lingual tonsillar hyperplasia, but more difficult and traumatic insertion of the LMA has been reported in that situation.7–9 In these two patients, insertion of the CTrach was easy and ventilation was adequate during the procedure, even though the epiglottis obstructed the view of the airway.

Downfolding of the epiglottis has been reported to be the most frequent cause of poor vision with the CTrach. In most cases, the "up–down" maneuver can achieve at least a partial view of the glottis.2,10 However, lingual tonsillar hyperplasia displaces the epiglottis backwards, making mobilization difficult and rendering the up–down maneuver useless. Lingual tonsillar hyperplasia may also prevent deeper insertion of the CTrach, which precludes placing the elevating bar under the tip of the epiglottis to expose the vocal cords. The net effect is that blind intubation with this device is nearly impossible in the presence of lingual tonsillar hyperplasia.

The first case occurred at the beginning of the CTrach evaluation in our hospital, in an anesthetized patient with no predicted difficult airway. The second case occurred after more than 50 intubations with the device by the same author (A.M.L.) and was the first failure during a continuing trial of awake intubation with the CTrach in patients with a suspected difficult airway.

In the first patient, the small size of the CTrach and lack of experience with the device might explain the failure to obtain an adequate view. However, the view obtained with a larger ILMA and fiberoptic bronchoscope in this patient was not better, suggesting that a larger CTrach would not have succeeded. We were unable to pass a 5-mm fiberoptic bronchoscope under the epiglottis with the ILMA in place. A thinner fiberoptic scope might have helped, but we preferred to withdraw the LMA and proceed directly to intubation using a fiberoptic bronchoscope.

In the second patient, the lingual tonsillar hyperplasia was immediately recognized. After several failed attempts to optimize the view we switched to awake fiberoptic intubation as dictated by our study protocol.

Patients with lingual tonsillar hyperplasia are a challenge for anesthesiologists. Several failures have been reported with different intubating approaches, including the ILMA and the fiberoptic bronchoscope.9 Goldman and Rosenblatt reported a successful CTrach intubation in an obese patient with lingual tonsillar hyperplasia, but a failed intubation with the ILMA and CTrach in the same patient several weeks later.11

In conclusion, the LMA-Ctrach is a new device for the management of difficult airways. However, in patients with airway pathology, such as lingual tonsillar hyperplasia, the CTrach may fail to provide an adequate view, preventing passage of the endotracheal tube.

ACKNOWLEDGMENTS

The authors thank Dr. Isabel Vilaseca for her quick assistance in confirming the diagnosis.

Footnotes

Accepted for publication March 17, 2008.

REFERENCES

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