Assessing the laryngeal view by conventional laryngoscopy after awake fibreoptic tracheal intubation

Abstract

A male patient who presented for surgery for vocal cord tumour was assessed in the pre-operative anaesthesia clinic. He had previously undergone C 2–4 cervical laminectomy. A difficult airway was predicted [1] as neck extension and jaw protrusion were very limited, he had a bull neck, was overweight and was Mallampati grade 3 [2]. His trachea was intubated using an awake fibreoptic technique, which proved difficult due to the laryngeal tumour. Conventional laryngoscopy was performed after the patient was anaesthetised. Minimal leverage with a size four Macintosh laryngoscope blade brought the larynx into full view, providing a Grade 1 view of the larynx [3]. This case highlights the importance of performing laryngoscopy by the conventional technique under general anaesthesia, after tracheal intubation using an awake fibreoptic technique. The view provided by conventional laryngoscopy can be graded and the ease or difficulty of subsequent attempts at intubation can therefore be predicted. In this case, it was reassuring to know that in the unlikely event of urgent re-intubation being required postoperatively, it would probably be achieved with ease using the conventional method. If this patient were to require anaesthesia in future, awake fibreoptic intubation would probably still be the best option, as airway maintenance using a facemask and airway might prove difficult. Possible distortion of the anatomy of the airway by radiotherapy would be further reason to proceed with an awake fibreoptic technique.