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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 48-51

Awake videolaryngoscopy-guided intubation in a patient with laryngocoele


Department of Anaesthesiology, Critical Care and Pain Medicine, AIIMS, New Delhi, India

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr. Yudhyavir Singh
Room No: 5011, Department of Anaesthesiology, Critical Care and Pain Medicine, AIIMS, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ARWY.ARWY_3_19

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  Abstract 


Laryngocoele is a rare, benign laryngeal disease causing a variety of symptoms. However, this condition can lead to upper airway obstruction, thus posing problems in airway management and ventilation. Therefore, prior planning of anaesthetic and airway management of such patients is desirable, wherein awake intubation techniques are safer methods of securing a definite airway. Awake videolaryngoscopy-guided intubation can be safely used as an alternative to awake fibreoptic bronchoscopy-guided intubation.

Keywords: Awake intubation, laryngocoele, videolaryngoscope


How to cite this article:
Singh Y, Acharya P, Behera A, Khanna P. Awake videolaryngoscopy-guided intubation in a patient with laryngocoele. Airway 2019;2:48-51

How to cite this URL:
Singh Y, Acharya P, Behera A, Khanna P. Awake videolaryngoscopy-guided intubation in a patient with laryngocoele. Airway [serial online] 2019 [cited 2019 Aug 18];2:48-51. Available from: http://www.arwy.org/text.asp?2019/2/1/48/257049




  Introduction Top


Laryngocoeles are rare, benign laryngeal swellings characterised by abnormal dilatation of the ventricular saccule of the larynx.[1],[2] They are cystic masses containing mainly air. There are three types of laryngocoele, namely internal, external and mixed laryngocoele based on their relationship with the thyrohyoid membrane. When the ventricular appendage increases in size, it extends medially and superiorly to the thyroid cartilage till it reaches the thyrohyoid membrane. If this dilated sac does not pierce the thyrohyoid membrane, it remains within the larynx resulting in an internal laryngocoele. If it pierces the thyrohyoid membrane, it becomes an external laryngocoele. A reported annual incidence of 1 per 2.5 million people makes it a relatively rare entity. Laryngocoeles can obscure the glottic view, thereby creating a difficult airway. Furthermore, these masses have been observed to cause life-threatening upper airway obstruction.[3] Herein, we describe the anaesthetic and airway management of a patient with a mixed laryngocoele.


  Case Report Top


A 58-year-old male presented with a history of occasional difficulty in breathing associated with foreign body sensation in the throat for the past 1 year. There was a swelling on the left side of the neck which progressively increased in size to the current size of approximately 3 cm × 3 cm. There was no history of hoarseness of voice, dysphagia, odynophagia, sore throat, chronic cough, stridor, exertional dyspnoea or snoring. The patient was a reformed smoker and was on medical management for hypertension with good control.

General physical and systemic examination of the patient was essentially normal. His airway evaluation showed an interincisor gap >5 cm, modified Mallampati Class II, positive upper lip bite test, normal neck movements and thyromental distance >6 cm with no loose teeth. Otorhinolaryngological examination revealed a non-tender, soft, reducible swelling over the upper one-third of the left side of the neck which increased in size during Valsalva manoeuvre. Indirect laryngoscopic examination revealed a cystic bulge in the left ventricle obscuring the view of the anterior endolarynx. Both the arytenoids were mobile. These findings were confirmed by fibreoptic examination. Biochemical investigations, chest X-ray and electrocardiogram were normal. Anteroposterior and lateral neck X-rays [Figure 1] and [Figure 2], ultrasound and computed tomogram [Figure 3] of the neck showed an air-filled cavity on the left side of the neck. A diagnosis of mixed laryngocele was made, and the patient was scheduled for transcervical excision of the lesion. In view of the anticipated difficult airway, the patient was counselled on the day before surgery regarding awake intubation. Informed written consent was obtained for tracheostomy. The patient was administered his antihypertensive drug and also given injection glycopyrrolate 0.2 mg intramuscularly 30 min before surgery.
Figure 1: Neck X-ray anteroposterior view showing air-filled cavity on the left side of the neck

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Figure 2: Neck X-ray lateral view showing air-filled cavity

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Figure 3: Computed tomography scan coronal view showing laryngocoele on the left side

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Standard monitoring including electrocardiogram, noninvasive blood pressure and pulse oximeter was established in the operating room, and an intravenous access was obtained. Fibreoptic intubation trolley and tracheostomy kits were kept ready. Intravenous midazolam 1 mg was administered, and three puffs of 10% lignocaine were sprayed topically to anaesthetise the oral airway including the posterior pharynx. Intravenous fentanyl 25 μg bolus was given thrice over 5 min, and oxygen was administered using nasal cannula. Gentle laryngoscopy was performed using #3 blade of the C-MAC videolaryngoscope, and a further two puffs of 10% lignocaine were administered over the glottic opening. The endotracheal tube was softened using warm saline. A 15-Fr, 65-cm long gum-elastic bougie (VBM Medical) was successfully inserted gently into the larynx under videolaryngoscopic guidance taking care not to rupture the cystic swelling, following which a 7.5-mm internal diameter cuffed endotracheal tube was railroaded over it [Figure 4] and [Figure 5]. Anaesthesia was induced with 80 mg propofol, and anaesthesia was maintained with isoflurane in air-oxygen and intermittent boluses of atracurium. Analgesia was provided with paracetamol 1 G, ketorolac 30 mg and boluses of fentanyl. Dexamethasone 8 mg was given to prevent laryngeal oedema. The surgical procedure lasted for 2 h, and the intraoperative course was uneventful. Residual neuromuscular blockade was antagonised at the end of surgery, and the patient was extubated after return of spontaneous respiration and response to verbal commands. The patient was shifted to the postanaesthesia care unit for observation. Postoperative recovery was uneventful.
Figure 4: Laryngocoele seen obstructing the glottic inlet

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Figure 5: Bougie passing through the glottic opening placed under the guidance of C-MAC videolaryngoscope

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  Discussion Top


Laryngocoeles are benign laryngeal swellings. They are often asymptomatic and are usually diagnosed incidentally.[1],[2] However, they may cause a variety of symptoms such as hoarseness, dysphagia or foreign body sensation. Rarely, they may lead to a potentially life-threatening upper airway obstruction with the patient presenting with stridor requiring emergent airway management and mechanical ventilation.[3] Airway management includes awake options, either fibreoptic intubation or under general anaesthesia with spontaneous respiration for children.[4],[5] In the presence of life-threatening airway obstruction, there may be a need for tracheostomy under local anaesthesia. Keeping in mind the above-mentioned concerns and anticipating difficult airway, we counselled our patient 1 day before surgery regarding the safety and choice of awake intubation. In addition, movement of the laryngocoele was minimised in the awake state by asking the patient to breathe slowly so that injury to the laryngocoele could be avoided. This was more important as the laryngocoele was located in front of the vocal cords. We softened the endotracheal tube by dipping it in warm water, and a bougie was inserted first after laryngoscopy to avoid injuring the laryngocoele by the blunt end of the bougie. Abrons et al. have shown that bougie-guided intubation causes significantly less trauma in nasopharyngeal intubation.[6]

Successful airway management was achieved by Rashid and Warltier as early as in 1989 using awake fibreoptic bronchoscopy (FOB).[7] Thus, we kept the fibreoptic bronchoscope ready for airway management. However, we preferred C-MAC videolaryngoscope over FOB and were successful in performing awake tracheal intubation in our patient. We used fentanyl and midazolam as sedation in this patient because of shorter onset time and peak of action. Performance of awake videolaryngoscopy is a very short procedure and easier than awake FOB. In recent years, dexmedetomidine has been widely used as a sole pharmacological agent or as an adjuvant for sedation during awake fibreoptic intubation. Dexmedetomidine has the advantage of providing sedation with minimal respiratory impairment. It also provides better haemodynamic stability and intubating conditions. However, the onset time of 5 min and peak effect of dexmedetomidine at 15 min are longer in comparison to fentanyl, thereby increasing the time to intubation. Fentanyl used by us also blunted the pressor response to awake intubation.

The C-MAC videolaryngoscope was preferred due to various advantages provided by it. Most importantly, the videolaryngoscope has been included as a rescue technique in airway management in various difficult airway algorithms.[8],[9],[10] The C-MAC videolaryngoscope has a quicker learning curve, making it an easier alternative for novice anaesthesiologists compared to FOB where expertise is mandatory for higher success rates.[11] Shorter time to achieve intubation has been observed with C-MAC videolaryngoscope as compared to FOB.[10] Furthermore, C-MAC provides a better view of glottis in the presence of secretions.[10] Lesser patient cooperation, sedation and local anaesthetic infiltration are desired advantages of the videolaryngoscope, thus avoiding the risk of oversedation and local anaesthetic toxicity in a difficult airway.


  Conclusion Top


We recommend that a videolaryngoscope such as a C-MAC videolaryngoscope can be used as a safe alternative to a fibreoptic bronchoscope for awake intubation in patients with laryngocoeles.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his image and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pennings RJ, van den Hoogen FJ, Marres HA. Giant laryngoceles: A cause of upper airway obstruction. Eur Arch Otorhinolaryngol 2001;258:137-40.  Back to cited text no. 1
    
2.
Soler EM, Vecina VM, Vintro XL, Agusti MQ, Vila JB, Juan MD. Laryngoceles: Clinical and therapeutic study of 60 cases. Acta Otorhinolaryngol Esp 1995;46:279-86.  Back to cited text no. 2
    
3.
Felix JA, Felix F, Mello LF. Laryngocele: A cause of upper airway obstruction. Braz J Otorhinolaryngol 2008;74:143-6.  Back to cited text no. 3
    
4.
Leong CL, Badran K, McCormick MS. Laryngocoele presenting as acute airway obstruction. Singapore Med J 2007;48:e84-6.  Back to cited text no. 4
    
5.
Sadeghi A, Memary E. Anesthetic approach in a child with laryngocele: A case study. Ann Anesthesiol Crit Care 2017;2:e11639.  Back to cited text no. 5
    
6.
Abrons RO, Zimmerman MB, El-Hattab YMS. Nasotracheal intubation over a bougie vs. non-bougie intubation: A prospective randomised, controlled trial in older children and adults using videolaryngoscopy. Anaesthesia 2017;72:1491-500.  Back to cited text no. 6
    
7.
Rashid J, Warltier B. Awake fibreoptic intubation for a rare cause of upper airway obstruction – An infected laryngocoele. Anaesthesia 1989;44:834-6.  Back to cited text no. 7
    
8.
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251-70.  Back to cited text no. 8
    
9.
Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult airway society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015;115:827-48.  Back to cited text no. 9
    
10.
Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.  Back to cited text no. 10
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11.
Salama AK, Hemy A, Rouf A, Saleh N, Rady S. C-MAC video laryngoscopy versus flexible fiberoptic laryngoscopy in patients with anticipated difficult airway: A randomized controlled trial. J Anesth Patient Care 2015;1:101.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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