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 Table of Contents  
Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 29-31

Bronchoscopic guided intubation through laryngeal mask airway in a patient with ankylosing spondylitis

1 Department of Anaesthesia, Kokilaben Dhirubhai Ambani Hospital and Research Institute, Mumbai, Maharashtra, India
2 Department of Anaesthesia, ESIC Hospital, Mumbai, Maharashtra, India

Date of Submission19-Aug-2022
Date of Acceptance24-Dec-2022
Date of Web Publication20-Apr-2023

Correspondence Address:
Dr. Senthilkumar Praveenkumar
Department of Anaesthesiology, Kokilaben Dhirubhai Ambani Hospital and Research Institute, Four Bungalows, Mumbai - 400 053, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_38_22

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Patients with ankylosing spondylitis present with airway difficulties. There are various techniques to secure a definitive airway for general anaesthesia in these patients. We report the case of an ankylosing spondylitis patient with fixed neck deformity for laparoscopic bilateral inguinal hernia repair surgery managed with an Ambu® AuraGain™ laryngeal mask (LM) insertion and followed by a fibreoptic bronchoscopic-aided endotracheal tube insertion for definitive airway through the LM airway according to the All India Difficult Airway Association guidelines.

Keywords: Ankylosing spondylitis, bronchoscopy, difficult airway, endotracheal tube, general anaesthesia, laryngeal mask

How to cite this article:
Praveenkumar S, Kapoor H, Malapaka D. Bronchoscopic guided intubation through laryngeal mask airway in a patient with ankylosing spondylitis. Airway 2023;6:29-31

How to cite this URL:
Praveenkumar S, Kapoor H, Malapaka D. Bronchoscopic guided intubation through laryngeal mask airway in a patient with ankylosing spondylitis. Airway [serial online] 2023 [cited 2023 Sep 21];6:29-31. Available from: https://www.arwy.org/text.asp?2023/6/1/29/374365

  Introduction Top

Ankylosing spondylitis is a progressive autoimmune disease of the axial skeleton more common in males. It causes annular fibrous ossification of joint cartilage and disc spaces of the spine. Ankylosis of the axial skeleton causes fusion and rigidity of the spine.[1] Involvement of the cervical spine reduces neck extension causing a 'chin-on-chest' deformity which poses a challenge in airway management. Conventional airway-securing techniques are often difficult and awake fibreoptic intubation is often necessary for these patients.

We present a patient with ankylosing spondylitis with fixed neck deformity posted for laparoscopic bilateral inguinal hernia repair.

  Case Report Top

A 50-year-old male with ankylosing spondylitis for 10 years was admitted for laparoscopic bilateral inguinal hernia repair. On examination, he had a fixed neck flexion deformity and required two pillows for resting his head in supine position as shown in [Figure 1]. His Mallampati classification was grade IV and the sternomental distance was reduced as shown in [Figure 2]. There was no neck extension. Our patient had adequate mouth opening. These patients are prone to atlantoaxial dislocation, hence the head was adequately supported. The rest of the general and systemic examinations were normal. Routine blood investigations were normal. Two-dimensional echocardiography showed all normal parameters. General anaesthesia was planned for the patient and the placement of endotracheal tube (ETT) with fibreoptic bronchoscope was planned and explained to the patient in detail. Before wheeling the patient into the operation theatre, lignocaine 4% nebulisation was given in the prehold bay. In the operation theatre, two pillows were given to support his neck and Trendelenburg position was given to aid mask ventilation.
Figure 1: View of the patient at the head end showing the distance between the head and the floor – fixed neck deformity

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Figure 2: Patient picture showing the fixed neck deformity with pillow

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Electrocardiogram, pulse oximetry and noninvasive blood pressure cuff were attached. The nasal tract was decongested with xylometazoline nasal drops and lignocaine jelly topical anaesthesia was given. However, the patient was uncooperative during awake fibreoptic intubation and refused further cooperation. The patient's mouth opening was not restricted and was found to be adequate; therefore, we planned to insert supraglottic device in the oral cavity. Inj. glycopyrrolate 0.2 mg iv was given. General anaesthesia was induced with propofol 2 mg/kg and atracurium 0.5 mg/kg was given. A laryngeal mask (LM) (Ambu® AuraGain) was placed. The LM achieved proper seal and adequate expired tidal volume was attained. After this with the help of Ambu aScope 4 Broncho Regular flexible endoscope, bronchoscopy was done through the LM and the vocal cords were visualised. A preloaded portex-cuffed ETT 7.0 was railroaded over the bronchoscope. The bronchoscope was removed and the correct placement of ETT was confirmed with appearance of proper capnograph. The LM was not removed as it was a shorter duration surgery and it could be helpful during extubation. Anaesthesia was maintained with sevoflurane in air–oxygen mixture. At the end of the surgery, after adequate reversal, the ETT was removed, but the LM was left in place. Once the patient was wide awake, the LM was removed. The patient was shifted to the postanaesthesia care unit and had an uneventful recovery.

  Discussion Top

Ankylosing spondylitis patients present with various difficulties for the anaesthesiologist to manage them with respect to the airway and systemic involvement for general anaesthesia. The involvement of the cervical spine and the temporomandibular joint[2] causing a fixed neck deformity of various degrees. The cervical spine is prone to fractures during manipulations[3] and this should be taken into consideration to avoid neurological injury and complications.[4]

Undue force cannot be applied during laryngoscopy and intubation. Awake fibreoptic bronchoscopic intubation is the standard technique in patients with anticipated difficult intubation. There are various strategies which can be carried out to secure the difficult airway for surgery depending on the availability of airway devices and the expertise. Blind nasal intubation, tracheostomy, Bullard laryngoscope, retrograde intubation, GlideScope,[2] Pentax Airway Scope, LMA FastTrack, TruView EVO2 optical laryngoscope[3] and the Aintree Intubation Catheter-guided fibreoptic intubation through a laryngeal mask airway[5] have been used to secure the airway in patients with ankylosing spondylitis successfully.

Our initial plan of proceeding with an awake fibreoptic intubation had to be abandoned as the patient became uncooperative. Since mouth opening for LM placement was found to be adequate, we chose to place an LM. In case general anaesthesia could not be given, the plan was to change the surgical plan to open hernia repair under nerve block. Ambu® AuraGain LM is routinely used in our institute. We planned to insert number 4 Ambu® AuraGain LM after confirming adequate ventilation under sedation with fentanyl, propofol and sevoflurane. The 2016 All India Difficult Airway Association guidelines do not recommend the use of ETT to be passed through the LM blindly.[6] We used a preloaded ETT of size 7 over an Ambu aScope 4 Broncho Regular flexible endoscope and railroaded it through the LM after a clear unobstructed view of the glottis seen. The assembly of the airway gadgets used is shown in [Figure 3]. The largest ETT that can be passed through the number 4 Ambu® AuraGain LM is 7.5 mm. On examination, the laryngeal mask placement was feasible and the ETT was guided through it for the laparoscopic surgery. Amongst many supraglottic airway devices, Ambu® AuraGain LM is a newer supraglottic airway designed to have an anatomical curve for smooth insertion and an adequate lumen for the passage of ETT.
Figure 3: Airway gadget assembly

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  Conclusion Top

Our technique of securing an ETT through an Ambu LM is a suggested technique for patients with fixed neck deformity when the patient does not give consent for an awake fibreoptic intubation. The advantages of this relatively newer supraglottic airway device are promising in difficult airway situations. However, case-based strategies need to be designed to manage such patients of ankylosing spondylitis with myriad airway difficulties based on the availability of airway gadgets.

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 be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sieper J, Braun J, Rudwaleit M, Boonen A, Zink A. Ankylosing spondylitis: An overview. Ann Rheum Dis 2002;61 Suppl 3:i8-18.  Back to cited text no. 1
Saringcarinkul A. Anesthetic considerations in severe ankylosing spondylitis. Chiang Mai Med J 2009;48:57-63.  Back to cited text no. 2
Vikas K. Airway management in a patient with severe Ankylosing Spondylitis. Indian J Basic Appl Med Res 2014;3:251-55.  Back to cited text no. 3
Woodward LJ, Kam PC. Ankylosing spondylitis: Recent developments and anaesthetic implications. Anaesthesia 2009;64:540-8.  Back to cited text no. 4
Ul Haq MI, Shamim F, Lal S, Shafiq F. Airway management in a patient with severe ankylosing spondylitis causing bamboo spine: Use of Aintree intubation catheter. J Coll Physicians Surg Pak 2015;25:900-2.  Back to cited text no. 5
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. 6
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