Awake Glidescope® intubation in patients with severe arytenoid swelling after laryngeal surgery with radiation therapy

Abstract

General anesthesia in patients who have previously undergone supracricoid partial laryngectomy (SCPL) and radiation therapy for laryngeal cancer is not common but a challenging task for anesthesiologists because of the distortion of the airway anatomy with stiff neck. A 42-year-old (171 cm, 73 kg) man was scheduled for inser tion of a percutaneous endoscopic gastrostomy (PEG) feeding tube under general anesthesia. One month before the referral, the patient had undergone SCPL and a bilateral neck dissection with tracheostomy and then adjuvant radiation therapy for laryngeal cancer. There was no problem with facial mask ventilation and intubation at that time. He was fed through a nasogastric tube. PEG insertion is generally performed under local anesthesia with sedative agents such as midazolam. However, he had a history of airway obstruction after intravenous administration of midazolam. Therefore, the gastroenterologists consulted us because his preoperative airway evaluation was expected to indicate difficult intubation (Fig. 1). We discussed a “can't intubate, can't ventilate (CICV)” state including mortality risks, and an awake intubation with the patient in details. However, as for a fiberoptic bronchoscopy (FOB), the patient refused. In case of critical situation, various kinds of laryngeal mask airway (LMA) and Glidescope Ⓡ (Verathon Inc., Bothell, WA, USA) were prepared, and there was no choice to leave an awake procedure as our last option. Sufficient preoxygenation (100% oxygen at 6 L/min over 5 minutes) was applied through a facial mask. Thiopental sodium 350 mg and succinylcholine 80 mg were administered for anesthetic induction. After the drugs, mask ventilation could not be effective. At that moment, immediate endotracheal intubation by direct laryngoscope was attempted with an armored tube (ID: 8.0 mm), and then a smaller tube (ID: 7.0 mm), however, these actions failed. The vocal cords could not be viewed because of swollen arytenoids with his stiff neck. We soon determined that he was in a CICV state. So we used supraglottic airway (LMA Igel Ⓡ , No 4) temporarily with little success. The patient regained consciousness and started breathing fortunately. His oxygen saturation (SpO2) by pulse oximetry remained above 97%. After