Anesth Pain Med.  2023 Apr;18(2):204-209. 10.17085/apm.23002.

Management of unanticipated difficult airway in a patient with well-visualized vocal cords using video laryngoscopy - A case report -

• Ki S
• Cho SB
• Park S
• Lee J

• KMID: 2543662
• DOI: http://doi.org/10.17085/apm.23002

Abstract

Background
Difficult airway occurs due to anatomical abnormalities of the airway that can be predicted through airway assessments; however, abnormalities beyond the vocal cord can be clinically asymptomatic and undetected until intubation failure to advance the endotracheal tube. Case: We present a case of an unanticipated difficult airway in a stuporous 80-year-old female with a recent history of intracerebral hemorrhage and prolonged intubation. She required emergency ventriculo-peritoneal shunt surgery due to the progression of her hydrocephalus. Under anesthesia, facemask ventilation was easy and video laryngoscopy provided a full view of the glottis; however, endotracheal tube (ETT) entry failed. We suspected stenosis beyond the vocal cord, and a smaller diameter ETT was inserted and maintained for airway management during emergency surgery. Postoperative neck computed tomography findings revealed laryngotracheal stenosis (LTS).
Conclusions
Anesthesiologists should be aware that LTS may be asymptomatic and consider difficult airway guidelines in patients with history of prolonged endotracheal intubation.

Keyword

Laryngostenosis; Airway management; Endotracheal intubation; Stupor; Ventriculoperitoneal Shunt

Figure

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  Fig. 1. Supine anteroposterior chest x-ray was taken on the day of emergency ventriculo-peritoneal shunt surgery. There are no suspicious signs of tracheal abnormality.

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  Fig. 2. Video laryngoscopy image was captured immediately after the second intubation failure. Posterior half of the true vocal cord is not fully visible due to edema. Erosion and inflammation are apparent in the posterior glottis.

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  Fig. 3. Axial (A), coronal (B), and midline sagittal section (C) of computerized tomography of the neck with 5.5 mm internal diameter cuffed reinforced endotracheal tube in place. Focal stenosis (white triangle) of the upper airway involves the subglottis and cervical part of the trachea. Enlargements of both thyroid glands with multiple nodules do not affect the cartilage structure of trachea.

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