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CASE REPORT
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 30-32

Dexmedetomidine and emergency front of neck access for acute stridor in advanced laryngeal carcinoma: Anesthetic challenges


Department of Anesthesiology and Critical Care, ABVIMS and Dr. RML Hospital, New Delhi, India

Date of Submission09-Mar-2022
Date of Acceptance28-Mar-2022
Date of Web Publication20-May-2022

Correspondence Address:
Dr. Amit Kumar
Department of Anesthesiology and Critical Care, ABVIMS and Dr. RML Hospital, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jica.jica_9_22

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  Abstract 

Supraglottic airway obstruction due to airway malignancy resulting in respiratory distress is a medical emergency requiring urgent re-establishment of airway patency, with tracheostomy to alleviate the stridor and threat to life. We report a 61-year-old male patient who presented with acute stridor, dyspnea, and a left-sided metastatic neck mass to the emergency room. The patient was rushed to the operation theater for emergency tracheostomy under monitored anesthesia care. We hereby discuss a successful surgical cricothyroidotomy, post failed emergency tracheostomy under dexmedetomidine infusion.

Keywords: Airway obstruction, awake emergency tracheostomy, dexmedetomidine, stridor, surgical cricothyroidotomy


How to cite this article:
Koul N, Hariharan U, Kumar A, Yadav N, Nagpal VK. Dexmedetomidine and emergency front of neck access for acute stridor in advanced laryngeal carcinoma: Anesthetic challenges. J Ind Coll Anesth 2022;1:30-2

How to cite this URL:
Koul N, Hariharan U, Kumar A, Yadav N, Nagpal VK. Dexmedetomidine and emergency front of neck access for acute stridor in advanced laryngeal carcinoma: Anesthetic challenges. J Ind Coll Anesth [serial online] 2022 [cited 2022 Nov 30];1:30-2. Available from: https://www.jicajournal.in//text.asp?2022/1/1/30/345606


  Introduction Top


Difficult airway management can be challenging and often call for individualized lifesaving decisions. Monitored anesthesia care (MAC) is a procedure during which sedation and analgesia is given together with local anesthesia while maintaining spontaneous breathing.[1] Emergency tracheostomy may be indicated for airway obstruction from tumors in the region of the larynx and hypopharynx.[2] Cricothyroidotomy, also known as “mini-tracheostomy,” is an emergency, lifesaving procedure performed for acute airway obstruction.[3] Furthermore, emergency cricothyroidotomy is a rescue-surgical technique for a failed airway in adults.[4] We report a patient in respiratory distress with stridor, in whom inability to localize the trachea during surgical exploration for tracheostomy due to locally advanced malignancy necessitated surgical cricothyrotomy performed under dexmedetomidine sedation.


  Case Report Top


A 61-year-old male known case of supraglottic cancer presented to the emergency room with grade 2 stridor, shortness of breath, difficulty in swallowing, voice change, and a left-sided metastatic squamous cell carcinoma neck measuring approximately 8 cm × 8 cm. He was planned for an emergency tracheostomy. History suggested a left-sided neck mass gradually increasing from the size of a pea to the current state. He was a follow-up case of supraglottic malignancy from a peripheral hospital. After instituting standard ASA monitors, preoperative vital parameters were heart rate of 130 bpm, blood pressure of 160/100 mmHg, respiratory rate of 28/min, and oxygen saturation of 90% on room air. Chest auscultation showed reduced bilateral air entry with added sounds. Two wide bore intravenous cannulas and a left radial arterial line were secured under local anesthesia for real-time invasive pressure monitoring and arterial blood gas sampling. In view of anticipated difficult airway, screening neck ultrasound was done, which showed extensive growth in the midline lower neck, a large mass anterior to the larynx, and a narrow/irregular tracheal lumen deviated to the right side. To be on safer side due to supraglottic tumor causing critical airway narrowing, oral/nasal tracheal intubation was ruled out. An awake tracheostomy under MAC was planned with dexmedetomidine sedation. Intravenous injection metoclopramide 10 mg, injection pantoprazole 40 mg, and injection ondansetron 8 mg were given before starting the procedure. Minimal procedural sedation was achieved with intravenous injection midazolam 1 mg and injection dexmedetomidine loading of 0.5 mcg/kg over 10 min, followed by infusion at a maintenance dose of 0.5 mcg/kg/h with the patient maintaining spontaneous respiration. Intermittent intravenous esmolol 10-mg boluses were given to treat increases in arterial pressure and tachycardia. Oxygenation was maintained with pressure support ventilation with 100% oxygen by face mask. Awake tracheostomy was attempted by the ENT team in rose position. A vertical midline neck incision was given; neck exploration for the trachea was complicated with extensive tumor growth on the outline of the trachea and the presence of neck mass. Failed attempt to localize tracheal rings along with further airway compromise in the patient led to the need for extension of skin incision upward. Due to severe narrowing in the airway, a 3-mm internal diameter (ID) uncuffed endotracheal tube was placed initially, confirmed with bilateral air entry and capnometry, which was later changed by serial dilation to a 4.5-mm ID cuffed tracheostomy tube [Figure 1] and finally to a 6.0-mm cuffed tracheostomy tube. Direct laryngoscopy found an extensive aryepiglottic fold tumor with near occlusion of the glottis with thickening of true vocal cords. At completion of the procedure, injection dexmedetomidine infusion was tapered gradually. The patient was shifted to the recovery room on T-piece through a tracheostomy tube at 6 L/min maintaining 100% oxygen saturation and stable vital parameters. Subsequent computer tomography scan of the neck showed a mass from the aryepiglottic fold extending into the ipsilateral paraglottic space with thickening of the left true vocal cord encasing the internal jugular vein and internal carotid artery [Figure 2]. Furthermore, severe tracheal narrowing and deviation to the right side were noted along with extensive lymph node involvement in left levels 3 and 4. After stabilizing the patient, he was referred to surgical oncology and radiotherapy for further management.
Figure 1: Initial incision for tracheostomy which was later extended upward. Also note tracheostomy tube cuffed ID 4.5, which was later changed to cuffed ID 6.0 tracheostomy tube

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Figure 2: Coronal section of contrast-enhanced tomography shows thickening of the left true vocal cord, aryepiglottic fold with a mass extending into the ipsilateral paraglottic space

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  Discussion Top


This case report illustrates a case of severe upper airway obstruction posted for emergency tracheostomy, in which front of neck access was done through emergency cricothyrotomy under dexmedetomidine sedation. The role of ultrasound in prediction of difficult airway and cricothyroid membrane localization has also been stressed.

Tracheostomy in a patient with supraglottic malignancy is indicated either as an elective procedure in perioperative period for definitive surgery or as emergency in the case of delayed presentation in locally advanced tumors.

Point-of-care ultrasound has been advocated as a significant noninvasive tool for airway assessment in emergency medicine and anesthesia literature.[5],[6] Airway ultrasound assists in identification of relevant airway anatomy including cricothyroid membrane in a noninvasive manner and is useful in planning airway management.[6] During awake tracheostomy in patients with critical airways, appropriate and safe sedation and analgesia is needed with appropriate drugs in controlled dosage. Dexmedetomidine, an α2-receptor agonist does not cause respiratory depression within clinical dose range and has been described for sedation during awake tracheostomy.[7]

In patients with potential difficult intubation with probable loss of airway in an attempt to intubate orally/nasally, the American Society of Anesthesiologists recommends directly proceeding for invasive airway management,[8] which was followed in our case. Constant and constructive communication between anesthesia and surgical team is essential during difficult airway management, especially shared airway decisions.[9]

Routine training of anesthesiologists for cricothyrotomy (both needle and surgical) is paramount in managing emergency airways in addition to theoretical knowledge.[10]

This case highlights the importance of predicting a difficult airway and preparing to implement plan B in case plan A fails preoperatively. The importance of emergency cricothyrotomy in the case of failed tracheostomy has been elucidated. Furthermore, the emerging role of airway ultrasound and dexmedetomidine sedation during emergency front of neck access has been stressed.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sohn HM, Ryu JH. Monitored anesthesia care in and outside the operating room. Korean J Anesthesiol 2016;69:319-26.  Back to cited text no. 1
    
2.
Piepho T, Cavus E, Noppens R, Byhahn C, Dörges V, Zwissler B, et al. S1 guidelines on airway management: Guideline of the German Society of Anesthesiology and Intensive Care Medicine. Anaesthesist 2015;64 Suppl 1:27-40.  Back to cited text no. 2
    
3.
Hathiram BT, Rai R, Watve P, Khattar VS. Tracheostomy in head and neck cancers. Otorhinolaryngol Clin 2010;2:53-60.  Back to cited text no. 3
    
4.
McKenna P, Desai NM, Morley EJ. Cricothyrotomy. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537350/. [Last updated on 2021 Oct 21].  Back to cited text no. 4
    
5.
Gottlieb M, Holladay D, Burns KM, Nakitende D, Bailitz J. Ultrasound for airway management: An evidence-based review for the emergency clinician. Am J Emerg Med 2020;38:1007-13.  Back to cited text no. 5
    
6.
Adi O, Fong CP, Sum KM, Ahmad AH. Usage of airway ultrasound as an assessment and prediction tool of a difficult airway management. Am J Emerg Med 2021;42:263.e1-4.  Back to cited text no. 6
    
7.
Jun I, Kim KM, Lee SS, Yoo BH, Lee YY, Lim YH, et al. Sedation with dexmedetomidine during tracheostomy in severe tracheal stenotic patients. Korean J Crit Care Med 2013;28:314-7.  Back to cited text no. 7
    
8.
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251-70.  Back to cited text no. 8
    
9.
Patel A. The shared airway. Curr Anaesth Crit Care 2001;12:213-7.  Back to cited text no. 9
    
10.
Carvey MM, Baek WK, Gluschitz S, Hage R. The necessity of practical emergency cricothyroidotomy training during undergraduate medical education. Transl Res Anat 2020;19:100070.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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