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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 41-44

Management of difficult airway in Scheuermann's disease with trendelenburg position and conventional laryngoscopy


1 Department of Anaesthesiology, Shri Mahant Indresh Hospital, Dehradun, Uttarakhand, India
2 Department of Anaesthesiology, AIIMS, Rishikesh, India
3 Department of Anaesthesiology, SGRRIM and HS, Dehradun, Uttarakhand, India

Date of Submission04-Jan-2020
Date of Acceptance26-Mar-2020
Date of Web Publication30-May-2020

Correspondence Address:
Dr. Nishith Govil
Department of Anaesthesiology, AIIMS, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ARWY.ARWY_1_20

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  Abstract 


Scheuermann's disease is a type of progressive hyperkyphosis that commonly involves lower thoracic vertebrae. Deformity is extreme and rigid due to progressive subtle changes in the vertebral endplates. Such severe form of spinal deformity leads to difficult ventilation and airway management. Strategies for approaching such an airway in a resource-limited environment by using special positioning such as the Trendelenburg position have not been reported before. A number of case reports have elaborated the successful airway management of fixed-flexion deformity with the help of supraglottic airway devices, videolaryngoscopes, fibreoptic endoscopes and surgical airways. To facilitate ventilation and intubation with laryngoscopy using the McCoy blade, the patient was placed in a supine position with wedge supportive rolls under his head, neck and upper torso. However, as this position created difficulty in approaching the airway for direct laryngoscopy, the position of the operating table was modified to 30° Trendelenburg position. This made the approach to the airway very easy for the anaesthesiologist performing intubation. Though fibreoptic intubation and videolaryngoscope-aided intubation would have possibly made the airway approach even easier, in our resource-limited conditions, McCoy levering laryngoscope, intubating laryngeal mask airway and intubating bougie were the only airway equipment available to deal with this situation.

Keywords: Difficult airway, Scheuermann's disease, Trendelenburg position


How to cite this article:
Govil N, Kakkar B, Kumar P, Ghosh S. Management of difficult airway in Scheuermann's disease with trendelenburg position and conventional laryngoscopy. Airway 2020;3:41-4

How to cite this URL:
Govil N, Kakkar B, Kumar P, Ghosh S. Management of difficult airway in Scheuermann's disease with trendelenburg position and conventional laryngoscopy. Airway [serial online] 2020 [cited 2020 Jul 12];3:41-4. Available from: http://www.arwy.org/text.asp?2020/3/1/41/285423




  Introduction Top


Scheuermann's disease is a progressive hyperkyphosis that commonly involves lower thoracic vertebrae. Deformity is extreme and rigid due to progressive subtle changes in the vertebral endplates.[1] Such a severe form of spinal deformity often leads to difficult ventilation and airway management. Use of Trendelenburg position for managing such an airway in a resource-limited environment has not been reported before. After taking consent of the patient for possible publication of his medical condition without disclosing his identity, we report this case of difficult airway management in a patient with Scheuermann's disease by using Trendelenburg position and conventional laryngoscopy.


  Case Report Top


A 35-year-old male was posted for cervical laminectomy (anterior approach) due to progressive cord compression and associated symptoms. Preoperative evaluation revealed onset of the disease from the age of 16 which gradually progressed. The patient now presented with muscle weakness and sensory deficit in both the upper limbs. Neck pain started from the age of 16 years which progressed from minor pain on movement to moderate, continuous pain at present. Pain was present on the nape of neck, was nonradiating and was associated with progressive nuchal rigidity. The patient had no history of associated comorbid illness, and physical examination was normal except for a breath-holding time of 15 s. Airway examination revealed a Mallampati Class II airway with adequate mouth opening and a thyromental distance of 5 cm. Neck movement was restricted for both flexion and extension, eventually resulting in a fixed-flexion deformity. Due to the nonavailability of a videolaryngoscope or a fibreoptic endoscope for aiding in intubation, a preoperative indirect laryngoscopy was performed which revealed normal view of the vocal cords and epiglottis. Preoperative blood investigations were normal. Chest X-ray posteroanterior view showed prominent bronchovascular markings, while a lateral chest X-ray showed the deformity with approximate Cobb angle of 48°. Pulmonary function tests were suggestive of mild restrictive disease with reduced lung capacities. Echocardiography showed normal ejection fraction with no features of pulmonary hypertension. The patient was kept fasting for 8 h for solid food and given injection ranitidine 50 mg intravenous for aspiration prophylaxis. No sedation was given in premedication as per All India Difficult Airway Association (AIDAA) 2016 guidelines.[2]

Positioning of the patient was difficult due to the fixed deformity at thoracic vertebral level. The patient was placed in a supine position with wedge supportive rolls under the head, neck and upper torso. Preoxygenation was done in the supine position with head-up position of approximately 20° due to fixed-flexion deformity. As per the AIDAA guidelines, preoxygenation was done for 3 min with a proper fitting facemask and closed circuit. Oxygen was opened at a flow rate of 10 L/min to prefill the circuit, and continuous positive airway pressure of 5 cm H2O was applied to improve apnoeic time. However, this position created difficulty in approaching the airway for direct laryngoscopy, so the position of the operating table was modified to a Trendelenburg position [Figure 1]. A 30° Trendelenburg position made the approach to airway easier for the anaesthesiologist. All essential monitors were attached, and the difficult airway cart was kept ready with an intubating laryngeal mask airway and a soft intubating bougie. Neurologic monitoring with somatosensory-evoked potentials was not available during the surgery.
Figure 1: Trendelenburg position for airway access and radiology image showing hyperkyphosis

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The patient was induced with propofol and fentanyl. After assessing the ability to mask-ventilate, the patient was paralysed with vecuronium and intubated at the first attempt using a McCoy levering laryngoscope. Maintenance of anaesthesia along with controlled hypotension was done as per the standard protocol of our department. Surgery was performed in Trendelenburg position to ensure adequate surgical exposure. The intraoperative period remained uneventful, and the patient was extubated after he became fully awake at the end of surgery.

Postoperatively, the patient was monitored and cared for in the postanaesthesia care unit by a multidisciplinary team. Pneumatic compression stockings applied at the time of induction of anaesthesia were continued for 48 h to prevent thromboembolic events. Multimodal analgesia was given postoperatively, and the patient had no additional sensorimotor deficit following surgery. The patient remained well until discharge from the ward 7 days later, and he had a good recovery.


  Discussion Top


Scheuermann's disease is diagnosed radiologically as thoracic kyphosis greater than 40° to 45° with anterior wedging of three consecutive vertebrae along with Schmorl's nodes (herniation of the nucleus pulposus in vertebral bodies). This is a disease of adolescence that more commonly affects boys. It has a familial predisposition with a worldwide incidence varying from 1% to 8%. Kyphosis is due to defective end plates, osteochondrosis of the vertebral bodies or mechanical trauma, but most often, the cause is idiopathic. Patients present with external deformity, pain in thoracolumbar area and less commonly with neurological deficit. Radiographic appearance is characteristic for making a diagnosis and necessary for arriving at treatment decisions. The degree of kyphosis in these cases can be determined with the help of ‘the sagittal balance’ in the sagittal view of full-length X-ray of spine. This horizontal distance is > 1.7 cm, and the kyphotic angle is generally >50° in Scheuermann's disease.[3]

Scheuermann's disease poses many challenges for the attending anaesthesiologist. Foremost among them is the approach to the airway and positioning for any central line insertion or surgical exposure. Even where videolaryngoscopes were available, placing the patient in a ‘neutral’ or ‘ramped’ position resulted in a lower incidence of difficult videolaryngoscopy than the conventional sniffing position.[4] Availability of a fibreoptic intubation scope or a videolaryngoscope would have made the airway approach relatively easier, but in our resource-limited conditions, only the McCoy levering laryngoscope, intubating laryngeal mask airway and intubating bougie were available. Reverse Trendelenburg position or ramped-up positions have been used for obese patients while the sniffing position is the conventional position for laryngoscopy.[2] A number of case reports have mentioned about the successful management of fixed-flexion deformity in post-burn contracture or spine anomaly with the help of contracture release under local anaesthesia, supraglottic airway devices (most notably Ambu laryngeal mask airway due to its preformed curvature), videoscopes, fibreoptic endoscopes and surgical airways. Our patient had adequate mouth opening which allowed easy introduction of the McCoy blade into the oral cavity. Had we been unsuccessful in visualising the glottis, our alternate option was an intubating laryngeal mask airway, with the final option being a surgical airway.

Patients with Scheuermann's disease also have altered respiratory function due to decrease in lung compliance and vital capacity. There may be concomitant increase in pulmonary vascular resistance and in long-standing cases, right heart failure. Patients with Cobb angle >60° are at high risk for respiratory and cardiovascular failure in the postoperative period.[5]


  Conclusion Top


Proper planning before conventional laryngoscopy and Trendelenburg position instead of head-up position in a resource-limited scenario is useful in the successful management of difficult airway in patients with fixed-flexion deformity as is seen in Scheuermann's disease.

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 images and other clinical information to be reported in the journal. The patient understands that his name and initials will not 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.
Swischuk LE, John SD, Allbery S. Disk degenerative disease in childhood: Scheuermann's disease, Schmorl's nodes, and the limbus vertebra. MRI findings in 12 patients. Pediatr Radiol 1998;28:334-8.  Back to cited text no. 1
    
2.
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. 2
[PUBMED]  [Full text]  
3.
Roussouly P, Nnadi C. Sagittal plane deformity: An overview of interpretation and management. Eur Spine J 2010;19:1824-36.  Back to cited text no. 3
    
4.
Aziz MF, Bayman EO, Van Tienderen MM, Todd MM; StAGE Investigator Group, Brambrink AM. Predictors of difficult videolaryngoscopy with GlideScope® or C-MAC® with D-blade: Secondary analysis from a large comparative videolaryngoscopy trial. Br J Anaesth 2016;117:118-23.  Back to cited text no. 4
    
5.
Tsiligiannis T, Grivas T. Pulmonary function in children with idiopathic scoliosis. Scoliosis 2012;7:7.  Back to cited text no. 5
    


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