Successful use of laryngeal mask airway for a patient with tracheal stenosis with tracheobronchopathia osteochondroplastica.

Abstract

To the Editor: Tracheobronchopathia osteochondroplastica (TO) is a rare benign disease with an accumulation of bony and cartilaginous nodules in the tracheal and bronchial mucosa (1). TO is sometimes found by tracheal intubation (2), and it can be a cause of difficult intubation. A 74-yr-old woman was scheduled for laparoscopic hepatectomy under general anesthesia. She did not have any respiratory symptoms prior to operation. The clinical examination of the heart and lungs was normal. Tracheal intubation was tried with an endotracheal tube (inner diameter, 7.0 mm) but was unsuccessful. The cuff inflation of a smaller diameter tube (inner diameter, 6.5 mm) pressed the vocal cord under ventilation. The bronchofiberscopy passed through the tube. A tracheal stenosis was revealed by bronchofiberscopic examination. Even if the smaller diameter endotracheal tube could be inserted into the trachea, it might cause complications (edema, bleeding, perforation) of tracheal lesions. The operation was postponed because a malignant tracheal tumor was suspected. By bronchofiberscopy, multiple nodular lesions from the vocal cord to the carina were found (Fig. 1). By CT-scanning the tumorous stenotic part was 35 mm distal from the vocal cord, horizontal diameter 3–4 mm. The tumor was not malignant by pathological diagnosis. The diagnosis was TO. A month later, laparoscopic partial resection of the liver was planned. We selected a Laser Flex® tracheal tube (Mallinckrodt® ID5.5 OD7.9). We shortened the distance from the distal end to the cuff by 5 mm. On the second anesthetic course, we tried tracheal intubation, however, the distance from the vocal cord to the tumor was still short for the cuff inflation. The inflation of the cuff could cause an edema of the vocal cord. The decision was made to use a laryngeal mask airway (#3) with controlled ventilation. Each surgical procedure and anesthesia was completed uneventfully.Figure 1: Bronchofiberscopy view: The numerous bony and cartilaginous nodules are present at the anterior and lateral aspects of the tracheal wall.Eckhardt et al. reported that laryngeal mask airway (LMA) was used as an air leak blocker after a 7.0-mm endotracheal tube was inserted during tracheoplasty of a patient with TO (3), whereas, to our knowledge, our case was the first report where LMA was used under intermittent positive pressure ventilation for a patient with TO. A nasogastric tube was inserted in our case. LMA cannot completely prevent gastric regurgitation under intermittent positive pressure ventilation. Currently, LMA-ProSeal™ (Laryngeal Mask Company) is available, and it has a drainage tube with improved sealing. LMA-ProSeal™ may be useful for performing intermittent positive pressure ventilation in a difficult airway patient with TO. In conclusion, LMA was used successfully with a muscle relaxant under intermittent positive pressure ventilation for a patient with TO. Hideaki Ishii, MD Hideyoshi Fujihara, MD, PhD Toyofumi Ataka, MD, PhD Hiroshi Baba, MD, PhD Tomohiro Yamakura, MD, PhD Toshiyuki Tobita, MD, PhD Kiichiro Taga, MD, PhD Koki Shimoji, MD, PhD, FRCA