Title: Difficult airway in a patient with prior neck radiation and cervical fusion
Primary presenting author: Wenli Ma M.D.
Faculty Mentor: Avner Gereboff M.D.
Institution: Cedars-Sinai Medical Center
Background: This case report details a 54 year old male with a history prior cervical fusion at the C3-C4 level, and a history of pharyngeal squamous cell carcinoma status post chemo and radiation therapy, going for a posterior cervical spinal fusion procedure. Physical exam exposed mallampati II, severely limited neck range-of-motion where neck and jaw are mostly fixed, poor mouth opening, and limited jaw protrusion.
Methods: This is a case report for a surgery that took place in July 2016, at Cedars-Sinai Medical Center.
Results: After induction, the resident was unable to ventilate the patient. The attending physician successfully mask ventilated using two hand mask ventilation with an oral airway and the neck in a neutral position. Tidal volumes were up to 400 cc/breath with a peak pressure of 15 cmH2O. Paralysis with rocuronium was then administered. Subsequently, we were unable to ventilate with either two hand mask ventilation with an oral airway or a laryngeal mask airway (LMA). While the patient had not desaturated, the attending called for a knife for cricothyrotomy and the assistance of additional anesthesiologist, who was then able to ventilate with a size four LMA after it was repositioned. This regular LMA was used as an intubating LMA when we advanced an aintree catheter through the hole of the LMA. A fiberoptic intubation was then performed with an aintree catheter placed over the fiberoptic bronchoscope. The area under the epiglottis to the vocal cords was extremely narrow. After insertion of the aintree catheter into the trachea, a 7.5 ETT tube was passed over the device.
Conclusion: My presentation will discuss the special considerations in post-radiation and cervical fusion airways. Radiation causes necrosis and fibrosis of the airway making both mask ventilation and intubation difficult. Prior cervical fusion also makes both mask ventilation and intubation difficult because it greatly reduces the neck range-of-motion, it is therefore difficult to accomplish the sniffing position. Fiberoptic intubation is often the the best airway management for these fused patients. Rocuronium is an acceptable choice of paralysis agent in difficult airways now that we have the new drug sugammadex, its fast onset can readily reverse rocuronium’s effect . However, in institutions with no available sugammadex, if one suspects a difficult airway based on the preoperative assessment, one should avoid using rocuronium due to long-lasting effects; and succinylcholine is a better choice in these situations due to its quick-on and quick-off effects.
