Awake tracheotomy is the airway management of choice for patients with severe dyspnea due to locally advanced obstructive head and neck squamous cell carcinoma. These patients are frequently difficult to ventilate and intubate, and tracheotomy should be performed before complete obstruction occurs. When tracheotomy is not possible in an emergent situation, other options for immediate airway control must be available and a team approach is essential.
We present the case of a 56 year old male with squamous cell carcinoma of the mouth floor invading the right mandible, complicated by significant bilateral cervical lymphadenopathy. He presented to our medical center with increasing dyspnea, dysphagia, poor PO intake, and acute enlargement of a submental mass over the previous few days that was found to be necrotic and infected. He was admitted for failure to thrive and initiation of IV antibiotics. Because of his growing airway tumor leading to near complete obstruction of his airway, he was scheduled for elective awake tracheotomy with local anesthetic and monitored anesthesia care. Upon presentation to the operating room, he was in respiratory distress but still breathing spontaneously in the left lateral decubitus position. Upon positioning the patient supine, his upper airway became completely obstructed. Returning to lateral position and applying two-handed mask ventilation with a nasopharyngeal airway was only able to maintain oxygen saturation at 60%. Unable to quickly perform a tracheotomy with the patient’s lateral position and abnormal anatomy, the otolaryngologist performed a successful emergency nasal fiberoptic intubation followed by tracheotomy under general anesthesia.
This case underscores the tenuous state of patients with advanced obstructive head and neck squamous cell carcinoma, and the importance of careful planning, examination of prior studies for descriptions of anatomy, and preparation for emergency airway scenarios.
