This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Dabbagh, A. Articles by Chamkhale, I. B. Search for Related Content PubMed PubMed Citation Articles by Dabbagh, A. Articles by Chamkhale, I. B. Related Collections Airway Patient Safety

---

PATIENT SAFETY

A Rapidly Enlarging Neck Mass: The Role of the Sitting Position in Fiberoptic Bronchoscopy for Difficult Intubation

Ali Dabbagh, MD^*, Naseraddin Mobasseri, MD^*, Hedayatollah Elyasi, MD^*, Babak Gharaei, MD^*, Mohammadreza Fathololumi, MD, Mahshid Ghasemi, MD^*, and Iman Bandarchi Chamkhale, MD^*

From the *Department of Anesthesiology, and Department of Otorhinolaryngology, Taleghani Hospital, Shahid Beheshti University, M.C. Tehran, Iran.

Address correspondence and reprint requests to Ali Dabbagh, MD, Department of Anesthesiology and Anesthesia Research Center, Shahid Beheshti University, M.C. Tehran, Iran. Address e-mail to alidabbagh{at}yahoo.com.

Abstract

Difficult airway management is a dilemma for any anesthesiologist. Although practice guidelines and algorithms may help in such situations, the anesthesiologist's judgment and vigilance remain the primary means to save lives. In the following case, we encountered an acutely enlarging thyroid mass that was compromising the airway. This huge neck mass precluded tracheostomy under local anesthesia, and the patient could breathe only in the sitting position. Therefore, there were few safe strategies for airway management for general anesthesia. We reiterate the role of awake fiberoptic intubation in such circumstances.

Management of the difficult airway presents a great dilemma for the anesthesiologist. Practice guidelines and algorithms may help in such situations. However, the anesthesiologist's judgment and vigilance remain the primary means to safe airway management. Neck masses from different sources may affect the airway and are potential causes of a difficult airway.1–8 There are few options for securing the airway in a patient with acutely enlarging and airway-compromising anterior neck mass, such as thyroid tumors. These patients may not tolerate the supine position due to stridor and tracheal compression. The utility and safety of performing tracheostomy in the awake patient prior to induction of general anesthesia are debatable, due to the location of the mass and the displaced anatomy it produces. Awake fiberoptic intubation remains a safe and effective method in experienced hands. A case of difficult intubation due to an enlarging neck mass is discussed, which describes the role of sitting fiberoptic bronchoscopy for managing this potentially catastrophic situation.

Case Presentation

A 41-yr-old woman with thyroid cancer was referred to a tertiary care University hospital for her follow-up visit. The mass in her anterior neck had been diagnosed as thyroid follicular cell carcinoma 3 yr previously, resulting in two separate thyroid surgeries without total eradication. In follow-up visits, metastases to her mediastinum were detected. Her care was planned to include chemo-radiotherapy with regular visits and tumor biopsies as needed.

During one of the follow-up visits, she had a small thyroid mass, with stable physical findings. After completion of the physical examination, she complained of shortness of breath, and was admitted to the hospital for observation. During the ensuing several hours, the tumor enlarged acutely (Figs. 1 and 2), and her respiratory condition deteriorated. The patient could not open her mouth, air hunger worsened, and air exchange was possible only in a sitting position.

View larger version (90K): [in this window] [in a new window]   Figure 1. The left semilateral sitting view.

View larger version (66K): [in this window] [in a new window]   Figure 2. The right semilateral sitting view.

Awake nasal fiberoptic intubation with the patient in the sitting-position, after surgical tracheotomy during general anesthesia, was considered the best option. The technique and its underlying reasons were explained to the patient, and she was asked to be as calm and cooperative as possible. Although the patient was seated and supported by an anesthesiologist, the standard monitoring devices (electrocardiogram, pulse oximetry, noninvasive arterial blood pressure, and end-tidal carbon dioxide monitor) were attached to the patient. A nasal cannula was set in front of the patient's teeth with an oxygen flow of 6 L per minute. Then, 1.5 µg/kg fentanyl and 0.5 mg atropine were injected intravenously. The nasal passage was prepared with a mixture of 2% lidocaine and 0.25% phenylephrine using 3 cotton-tip applicators in different directions to achieve topical anesthesia. The base of the tongue and the pharyngeal walls were anesthetized with 10% lidocaine spray (total dose of 50 mg). Topical anesthesia of the larynx and trachea was achieved with topical lidocaine spray (total dose, 75 mg). The endotracheal tube was warmed to make it more pliable during its nasal insertion. The lubricated endotracheal tube was passed through the prepared nostril into the pharynx. The fiberoptic bronchoscope was passed through the endotracheal tube, the glottis was identified, and the fiberoptic bronchoscope was advanced into the trachea. The endotracheal tube was advanced over the fiberoptic bronchoscope beyond the true vocal cords, but it could not be advanced easily beyond this point, most likely because of an extension of the metastasis into the trachea. This assumption was later corroborated by the anteroposterior radiograph (Fig. 3). Constant gentle pressure was exerted on the endotracheal tube until it was advanced into the trachea distal to this stricture. At this point, auscultation of the lung fields revealed bilateral air exchange. Thereafter, the patient could lie supine on the operating table, sedated but awake. IV anesthetic induction was safely accomplished after the endotracheal tube was secured.

View larger version (60K): [in this window] [in a new window]   Figure 3. The anteroposterior radiograph taken preoperatively: the arrow denotes the probable site of intratracheal tumor metastasis which caused a hindrance in tube passage.

The tracheostomy was technically very difficult. Surgeons limited their procedure to tracheostomy with no thyroid exploration. The procedure lasted almost 2 h, with a blood loss of approximately 1000 mL. The patient made a good postoperative recovery, requiring only a 2-day stay in the intensive care unit.

Further investigations while in the hospital revealed local bleeding and inflammatory undifferentiated thyroid carcinoma, for which she underwent thorough evaluation and treatment.

DISCUSSION

Neck masses from different sources may affect the airway.1–8 Thyroid tumors are a potential cause for difficult airway management. However, they rarely become an acute danger to the airway. Few cases of hemorrhagic thyroid mass with resultant respiratory distress have been reported.5,7 In this case, thyroid manipulation during an examination caused tissue hemorrhage into the thyroid mass, which enlarged massively in just a few hours.

Awake fiberoptic intubation remains the "gold standard" for anticipated difficult intubation.1 Blind nasal or oral intubation is a simple technique, but it is associated with two major drawbacks: infrequent success on the first pass, and increased trauma with repeated attempts. We could not risk precipitating complete airway obstruction that necessitated emergent cricothyrotomy.6 Also, insertion of the endotracheal tube via the nasal passage increases risk of nasal bleeding. This can result in an inability to visualize subsequent fiberoptic attempts due to both tissue edema and bleeding. Previous studies indicated fiberoptic nasotracheal intubations is associated with frequent failure (66% in some studies).6 However, there are reports of a greater success rate with this procedure, attributed to a well-organized approach, and expertise in flexible bronchoscopy.1,6

Avoiding airway irritation and laryngeal spasm is critical in preventing sudden airway loss. Most authors believe that using local anesthetics on the oropharyngeal cavity for patient cooperation is mandatory. However, application of topical anesthesia is at times unpleasant for the patient and may precipitate cough and laryngeal spasm.6 Also, some investigators have suggested that application of topical anesthesia to the oropharynx is either not necessary during nasal intubation, or that its efficacy is modest with some mass lesions.1–3

Tracheostomy using local anesthesia has been considered the "definitive modality" of airway management in situations such as deep neck infections.6–8 Nevertheless, it may be difficult or impossible in advanced cases such as ours because of the patient's position needed for tracheostomy, or due to the anatomical distortion of the anterior neck. In our case, surgeons were reluctant to perform tracheostomy using local anesthesia without a secure airway.1,5,8

Sitting fiberoptic bronchoscopic intubation was life-saving for our patient. Therefore, we suggest that anesthesiologists occasionally practice this technique so that it may be used when confronted with a patient requiring awake urgent intubation who cannot tolerate the supine position.

ACKNOWLEDGMENTS

The authors acknowledge the general surgery, otolaryngology, and oral and maxillofacial surgery teams, and the nursing staff of Taleghani hospital for their support and contribution to the successful outcome of this very complicated patient.

Footnotes

Accepted for publication June 13, 2008.

REFERENCES

1. Ovassapian A. Fiberoptic Endoscopy and the Difficult Airway. 2nd ed. Philadelphia: Lippincott-Raven Press, 1996
2. Belmont MJ, Wax MK, DeSouza FN. The difficult airway: cardiopulmonary bypass—the ultimate solution. Head Neck 1998;20:266–9[Web of Science][Medline]
3. Hariprasad M, Smurthwaite GJ. Management of a known difficult airway in a morbidly obese patient with gross supraglottic oedema secondary to thyroid disease. Br J Anaesth 2002;89:927–30[Abstract/Free Full Text]
4. Huitink JM, Balm AJ, Keijzer C, Buitelaar DR. Awake fibrecapnic intubation in head and neck cancer patients with difficult airways: new findings and refinements to the technique. Anaesthesia 2007;62:214–9[Web of Science][Medline]
5. Oka Y, Nishijima J, Azuma T, Inada K, Miyazaki S, Nakano H, Nishida Y, Sakata K, Hashimoto J, Izukura M. Blunt thyroid trauma with acute hemorrhage and respiratory distress. J Emerg Med 2007;32:381–5[Web of Science][Medline]
6. Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: a case series and review of the literature. Anesth Analg 2005;100:585–9[Abstract/Free Full Text]
7. Tsilchorozidou T, Vagropoulos I, Karagianidou C, Grigoriadis N. Huge intrathyroidal hematoma causing airway obstruction: a multidisciplinary challenge. Thyroid 2006;16:795–9[Web of Science][Medline]
8. Heidegger T, Gerig HJ. Algorithms for management of the difficult airway. Curr Opin Anaesthesiol 2004;17:483–4[Medline]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Dabbagh, A. Articles by Chamkhale, I. B. Search for Related Content PubMed PubMed Citation Articles by Dabbagh, A. Articles by Chamkhale, I. B. Related Collections Airway Patient Safety