“Cannot Intubate, Cannot Ventilate” Scenario and Failed Tracheostomy in a Patient with Massive Neck Swelling: A Case Report

Abstract

Introduction: Neck swelling associated with airway obstruction is a significant challenge in airway management. When the neck swelling is very large and the airway anatomy is grossly distorted, even surgical tracheostomy may prove impossible. Case report: We present a case of massive neck swelling causing airway compromise, complicated by difficult ventilation, intubation and failed tracheostomy. A 53-year-old woman presented with a submandibular swelling, diagnosed as Ludwig's angina. However she refused surgical intervention and only agreed to antibiotics. Six weeks later, she came in again with airway compromise. Endotracheal intubation was attempted in the operating theatre with otorhinolaryngology (ENT) surgeon backup. Intubation was difficult by direct laryngoscope and Glidescope video laryngoscope. Mask-ventilation and Proseal ventilation later became impossible. Emergency tracheostomy also failed because the trachea could not be located. She developed hypoxic cardiac arrest. Conclusion: Acute airway obstruction from massive neck swelling should be jointly managed by the anaesthetist, surgeon and a well-informed team in the operating theatre. Conscious sedation using dexmedetomidine or remifentanil infusion may allow the use of fibreoptic intubation in un-cooperative patients.