Total Airway Obstruction with Neck Extension: Airway Management of a Patient with Pharyngeal Tumor
John E. Tetzlaff, MD,* Ramesh Patel, MD,? Gregory Milmoe, MD$ Departments
of Anesthesiology
dation,
Cleveland,
ington,
DC.
OH,
and
and Otolaryngology, Children’s
Hospital
The Cleveland
National
Medical
Clinic Center,
FounWash-
Airway obstruction with the induction of anesthesia in chil-
vlc~.\opha~r~~~eal tumor. Flexion rather than extension of’the
dren zs common. Normally, neck extension with jaw thrust
vlrck r&z&
improves the airway. Flexion typically completes the obstruc-
radiologic studies with neck extension and flexion iv) Juch (‘IL.\ P.\
tion. With the presence of a phavyngeal tumor, these relationships may not be the same. We present a case of complete airway obstru,ction with neck extension in the presence of a
J. Clin. Anesth. 3:406-408,
this airway obstruction. We highly recommend
Keywords: Airway, extension; pediatrics; anesthesia.
tumor, pharyngeal:
1991
Introduction *Staff Anesthesiologist, Department Cleveland Clinic Foundation
of General
tStaff
Anesthesiologist, Department of Anesthesia, pital National Medical Center; Assistant Professor ogy, George Washington University, Washington,
Anesthesia,
The
Children’s Hosof AnesthesiolDC
$Staff Anesthesiologist, Department of Otolaryngology, C:hildren’s Hospital National Medical Center; Assistant Professor of Otolaryngology, George Washington University, Washington, DC Address reprint requests 10 Dr. Tetzlaffat the Department eral Anesthesia, The Cleveland Clinic Foundation, 9500 Avenue, Cleveland, OH 4419.5, USA. Received for publication October 10, 1990; revised cepted for publication .January 25, 1991.
of GenEuclid
manuscript
0 3991 Butterworth-Heinemann
406
J. Clin. Anesth.,
vol. 3, September/October
1991
ac-
We present a case in which we encountered difficulty in managing the airway during induction of anesthesia in a child with a large nasopharyngeal tumor.l,’ Unusual maneuvers were required to maintain a patent airway.
Case Report An X-year-old, 33 kg black male, in normal health until 6 weeks prior to admission, was brought to the emergency room with symptoms of dysphonia, droolincreasing halitosis, and fever. Examination ing, showed a necrotic mass extending from the nasopharynx down to the base of the tongue and extending into the left pharyngeal wall. Intravenous (IV)
Total &way
Figure 1. Lateral neck radiograph showing the nasopha-
ryngeal mass extending to the tip of the epiglottis.
antibiotics were started for the bacterial superinfection of the necrotic tumor. A lateral radiograph (Figure 1) showed the mass extending to the tip of the epiglottis. A computerized axial tomogram (CAT) scan with contrast showed that the mass appeared to have small-vessel tumor vascularity and erosion of the surrounding bony structures. It also confirmed the radiographic findings that the mass occluded the nasopharynx (F@z~e 2) and extended to the epiglottis. Two CAT scan cuts, 0.5 cm apart, demonstrated the transverse epiglottic ligament on the inferior cut and the wide base of the tumor in the superior cut 0.5 cm above. A transnasal punch biopsy was nondiagnostic. The patient was scheduled for diagnostic endoscopy and excisional biopsy. The patient was alert, cooperative, and lying supine in bed with no motion restriction. He was ventilating normally without dyspnea or obstruction. Some drooling was noted, as was raspy phonation. In the awake state, air exchange did not change with neck motion. No premeditation was administered. Monitors placed in the operating room included a precordial stethoscope, an electrocardiogram (EKG), blood pressure (BP) measurement by Dinamap (Dinamap Critikon, Tampa, FL), and a temperature probe. Due to anticipated airway difficulty, induction was planned to be spontaneous ventilation of an inhalation agent in 100% oxygen (0,). The child was prepared and
obstruction with neck extemion:
Tetzlaff et al.
participated in spontaneous ventilation of halothane in 100% 0,. With unconsciousness, spontaneous ventilation remained, IV access was secured, and atropine 0.4 mg was administered. Laryngoscopy and intubation were planned under deep halothane anesthesia without muscle relaxant. With the deepening of anesthesia, however, progressively worsening airway obstruction developed. Extension of the neck produced complete obstruction. The tremendous size of the mass precluded use of an oral airway. Forward jaw thrust with continuous positive pressure improved ventilation slightly, but even in this position, cervical extension produced total airway obstruction. Dramatic improvement occurred when a combination of jaw thrust and cervical flexion was tried. Deepening of anesthesia was performed by mask with the neck in flexion. When an adequate depth of anesthesia was established, laryngoscopy was performed, and the trachea was intubated easily despite glottic deviation secondary to the tumor. Anesthesia was maintained with halothane, nitrous oxide (N,O), 0,, and atracurium. Brisk bleeding was encountered during excisional biopsy, necessitating transfusion of packed red blood cells. Estimated blood loss was 600 ml. At the conclusion of surgery, the muscle relaxant was reversed with atropine and neostigmine. When the child was fully awake, he was extubated without difficulty. The biopsy revealed a diagnosis of rhabdomyosarcoma. Planned therapy included radiotherapy and chemotherapy. Repeat anesthetic on the fifth postoperative day for the
Figure 2. Computerized axial tomogram (CAT) scans of the neck. The scan on the left is at the level of the epiglottis. The scan on the right demonstrates the tumor position 0.5 cm above the epiglottis.
J. Clin. Anesth., vol. 3, September/October
1991
407
placement of’ a Broviac catheter for chemotherapy was uneventful after nearly total removal of’the mass.
Discussion During inspiration, intrathoracic pressure is negative. Pressure as low as - 80 to - 100 cmH,O is transmitted to the nose during maximal inspiratory efforts against nasal occlusion.:’ The extrathoracic airway must resist closure during this period of’ negative pressure. ‘I’he pharyngeal airway in an awake subject remains patent due to the tone of’ the genioglossus and geniohyoid muscles. ’ Electromyographic (EM
John E. Tetzlaff, MD,* Ramesh Patel, MD,? Gregory Milmoe, MD$ Departments
of Anesthesiology
dation,
Cleveland,
ington,
DC.
OH,
and
and Otolaryngology, Children’s
Hospital
The Cleveland
National
Medical
Clinic Center,
FounWash-
Airway obstruction with the induction of anesthesia in chil-
vlc~.\opha~r~~~eal tumor. Flexion rather than extension of’the
dren zs common. Normally, neck extension with jaw thrust
vlrck r&z&
improves the airway. Flexion typically completes the obstruc-
radiologic studies with neck extension and flexion iv) Juch (‘IL.\ P.\
tion. With the presence of a phavyngeal tumor, these relationships may not be the same. We present a case of complete airway obstru,ction with neck extension in the presence of a
J. Clin. Anesth. 3:406-408,
this airway obstruction. We highly recommend
Keywords: Airway, extension; pediatrics; anesthesia.
tumor, pharyngeal:
1991
Introduction *Staff Anesthesiologist, Department Cleveland Clinic Foundation
of General
tStaff
Anesthesiologist, Department of Anesthesia, pital National Medical Center; Assistant Professor ogy, George Washington University, Washington,
Anesthesia,
The
Children’s Hosof AnesthesiolDC
$Staff Anesthesiologist, Department of Otolaryngology, C:hildren’s Hospital National Medical Center; Assistant Professor of Otolaryngology, George Washington University, Washington, DC Address reprint requests 10 Dr. Tetzlaffat the Department eral Anesthesia, The Cleveland Clinic Foundation, 9500 Avenue, Cleveland, OH 4419.5, USA. Received for publication October 10, 1990; revised cepted for publication .January 25, 1991.
of GenEuclid
manuscript
0 3991 Butterworth-Heinemann
406
J. Clin. Anesth.,
vol. 3, September/October
1991
ac-
We present a case in which we encountered difficulty in managing the airway during induction of anesthesia in a child with a large nasopharyngeal tumor.l,’ Unusual maneuvers were required to maintain a patent airway.
Case Report An X-year-old, 33 kg black male, in normal health until 6 weeks prior to admission, was brought to the emergency room with symptoms of dysphonia, droolincreasing halitosis, and fever. Examination ing, showed a necrotic mass extending from the nasopharynx down to the base of the tongue and extending into the left pharyngeal wall. Intravenous (IV)
Total &way
Figure 1. Lateral neck radiograph showing the nasopha-
ryngeal mass extending to the tip of the epiglottis.
antibiotics were started for the bacterial superinfection of the necrotic tumor. A lateral radiograph (Figure 1) showed the mass extending to the tip of the epiglottis. A computerized axial tomogram (CAT) scan with contrast showed that the mass appeared to have small-vessel tumor vascularity and erosion of the surrounding bony structures. It also confirmed the radiographic findings that the mass occluded the nasopharynx (F@z~e 2) and extended to the epiglottis. Two CAT scan cuts, 0.5 cm apart, demonstrated the transverse epiglottic ligament on the inferior cut and the wide base of the tumor in the superior cut 0.5 cm above. A transnasal punch biopsy was nondiagnostic. The patient was scheduled for diagnostic endoscopy and excisional biopsy. The patient was alert, cooperative, and lying supine in bed with no motion restriction. He was ventilating normally without dyspnea or obstruction. Some drooling was noted, as was raspy phonation. In the awake state, air exchange did not change with neck motion. No premeditation was administered. Monitors placed in the operating room included a precordial stethoscope, an electrocardiogram (EKG), blood pressure (BP) measurement by Dinamap (Dinamap Critikon, Tampa, FL), and a temperature probe. Due to anticipated airway difficulty, induction was planned to be spontaneous ventilation of an inhalation agent in 100% oxygen (0,). The child was prepared and
obstruction with neck extemion:
Tetzlaff et al.
participated in spontaneous ventilation of halothane in 100% 0,. With unconsciousness, spontaneous ventilation remained, IV access was secured, and atropine 0.4 mg was administered. Laryngoscopy and intubation were planned under deep halothane anesthesia without muscle relaxant. With the deepening of anesthesia, however, progressively worsening airway obstruction developed. Extension of the neck produced complete obstruction. The tremendous size of the mass precluded use of an oral airway. Forward jaw thrust with continuous positive pressure improved ventilation slightly, but even in this position, cervical extension produced total airway obstruction. Dramatic improvement occurred when a combination of jaw thrust and cervical flexion was tried. Deepening of anesthesia was performed by mask with the neck in flexion. When an adequate depth of anesthesia was established, laryngoscopy was performed, and the trachea was intubated easily despite glottic deviation secondary to the tumor. Anesthesia was maintained with halothane, nitrous oxide (N,O), 0,, and atracurium. Brisk bleeding was encountered during excisional biopsy, necessitating transfusion of packed red blood cells. Estimated blood loss was 600 ml. At the conclusion of surgery, the muscle relaxant was reversed with atropine and neostigmine. When the child was fully awake, he was extubated without difficulty. The biopsy revealed a diagnosis of rhabdomyosarcoma. Planned therapy included radiotherapy and chemotherapy. Repeat anesthetic on the fifth postoperative day for the
Figure 2. Computerized axial tomogram (CAT) scans of the neck. The scan on the left is at the level of the epiglottis. The scan on the right demonstrates the tumor position 0.5 cm above the epiglottis.
J. Clin. Anesth., vol. 3, September/October
1991
407
placement of’ a Broviac catheter for chemotherapy was uneventful after nearly total removal of’the mass.
Discussion During inspiration, intrathoracic pressure is negative. Pressure as low as - 80 to - 100 cmH,O is transmitted to the nose during maximal inspiratory efforts against nasal occlusion.:’ The extrathoracic airway must resist closure during this period of’ negative pressure. ‘I’he pharyngeal airway in an awake subject remains patent due to the tone of’ the genioglossus and geniohyoid muscles. ’ Electromyographic (EM
