Para pharyngeal Tumor with Airway Obstruction Choosing an Alternate Airway

Anusha B, Mohanty A, Krishna Prasad T and Dilip Kumar G

Published on: 2024-09-09

Abstract

A multi-lumen catheter guide has made the process of retrograde tracheal intubation easier. It would effortlessly follow the retrograde guide when utilized as an anterograde guide, guiding the endotracheal tube's insertion in an atraumatic manner. In order to prevent the endotracheal tube from dislodging from the laryngeal inlet, a novel approach is presented that enables stabilization of the anterograde catheter and its implantation deep inside the trachea.

In need of surgical resection was a 72-year-old man with a body mass index of 20.3 who had a pleomorphic adenoma extending into para pharyngeal space in the jaw that extended to the oropharynx and rhino pharynx. After consulting with the general surgery department and analyzing the imaging in computed tomographic (CT), our team decided to use a modified retrograde intubation to control the airway. The team's proficiency and skill with the procedure, the patient's prompt availability, and the tolerance of the percutaneous wire were some of the factors that led to the decision to proceed with retrograde intubation under moderate sedation. After discussing the possibilities with the patient, they decided to move forward. The patient was put to a supine position, with the head turned comfortably position of the patient, then slightly elevated to 15 degrees and the neck slightly extended, under standard monitoring. Using a target-controlled infusion pump, a combination of dexmedetomidine and fentanyl infusion was given intravenously to provide a moderate sedation that preserved spontaneous breathing. The nostrils were anesthetized by inserting a gauze soaked in lignocaine mixed with 1:200,000 epinephrine to improve comfort and reduce the likelihood of bleeding. Following the identification and imaging of features using ultrasound and anatomy, including the assessment of the thyroid isthmus and surrounding blood vessels, a 27-G needle was used to administer Lidocaine 2% transtracheally, a local anesthetic, between the first and second tracheal rings [1].

Keywords

Retrograde intubation; Difficult airway; Tuohy needle

Short Communication

With the bevel end facing the cephalic direction, an 18G Tuohy needle fitted with a saline-filled syringe was introduced through the membrane. Aspiration of air bubbles verified the position. On the second attempt, the 22 G Catheter (Tuohy: Portex) was placed and removed from the right nostril; initially, it headed to the oral cavity [2]. After that, the catheter was passed across it and into the trachea, ending at the tracheal wall. After the wire was removed, the airway exchange catheter was advanced further, and the results of the electrocardiogram, radiograph, and capnography, as well as five-point auscultation, were normal. Room air saturation was 98% with a Pulse rate of 82/min and Blood pressure of 120/70 millimeters of mercury. Assessed Under ASA 3. A 7-size flexometallic endotracheal tube was railroaded nasally over the catheter and successfully inserted into the trachea. The endotracheal tube was passed inside the trachea smoothly over the catheter and the catheter was withdrawn. The position of the tube was confirmed by auscultation and capnography [3]. The surgical procedure was uneventfully followed by which the patient was extubated and shifted to intensive care monitoring.

Since the laryngeal opening does not need to be located or navigated, this method of anterograde tracheal intubation is superior to standard techniques. Instead, during the tracheal tube's insertion, it is railroaded over a retrograde guide that was earlier inserted inside the larynx using percutaneous means. The author's goal is for the tracheal tube to pass through the upper airway and into the larynx by keeping its tip in the middle of the mouth and throat so that we do not cause spillage from adenoma.

References

  1. Morton T, Brady S, Clancy M. Difficult airway equipment in English emergency departments. Anesthesia. 2000; 55: 485-488.
  2. Contrucci RB, Gottlieb JS. A complication of retrograde endotracheal intubation. Ear, nose, & throat journal. 1990; 69.
  3. Normand KC, Aucoin AP. Retrograde Intubation. In: The Difficult Airway. Oxford University Press; 2013. 109-116.