Wire guided fibreoptic retrograde intubation in a case of glottic mass.

Sir,

A 65-year-old gentleman presented to our Otorhinolaryngology department, with a history of progressive change in voice and noisy breathing. Pre-operative nasopharyngolaryngoscopy revealed an exophytic growth involving left vocal cord extending into vestibule, arytenoid and anterior one-third of the right vocal cord. The left hemi larynx was fixed with restricted mobility of the right vocal cord as well, with posterior airway of 4–5 mm. A diagnosis of carcinoma glottis was made and he was posted for micro laryngoscopy and biopsy under general anaesthesia. Pre-anaesthetic evaluation of airway was Mallampati III with mild limitation of neck extension, thyromental distance of 5 cm and mouth opening of 3 finger breadths. The pre-operative room air saturation was 97% and inspiratory stridor was audible. The patient was not prescribed any sedative premedication, due to compromised airway. The life-saving back-up plan was emergency tracheostomy.

Our plan A was to proceed with awake fibreoptic intubation technique. Intravenous access was secured and monitors were placed as per the American Society of Anesthesiologists guidelines. An informed consent was taken after explaining the risks and benefits of the procedure. The patient's airway was topicalised with bilateral superior laryngeal nerve block and transtracheal block using 2% preservative-free lignocaine. Nebulisation was given using 4% lignocaine, and 10% lignocaine was used to spray the nostrils and supraglottic structures. Likewise, oxymetazoline was used to vasoconstrict the nasal mucosa. The total dose of local anaesthetic was kept within 9 mg/kg. The patient was very cooperative throughout the performance of airway blocks. A 4.0 mm fibreoptic bronchoscope (KARL STORZ) with a size 5.0 cuffed micro laryngoscopy endotracheal tube was loaded over it and introduced into the right nostril. The mass was seen occupying most of the supraglottic space, with no visible airway. It was oedematous, friable and we were reluctant to push the fibreoptic bronchoscope past it, blindly. It was observed that the mass had increased in size since last naso-pharyngo-laryngoscopy (NPL) [Figure 1]. We decided to proceed with wire-guided fibreoptic intubation, using a Terumo© urological J-tipped guide wire (size: 0.032 inches/150 cm).

Figure 1

Nasopharyngolaryngoscopy depiction of exophytic proliferative growth involving most supraglottic structures, with airway seen as slit-like opening beyond the growth

The cricothyroid membrane was identified and punctured in a cephalad direction, using an 18-gauge intravenous cannula (Insyte©). The cannula placement was confirmed by aspirating air, with a saline-filled syringe. Following this, the guide wire was introduced in a retrograde fashion through the cannula, with fibreoptic bronchoscope in position above the supraglottic mass. The guide wire was negotiated posterior to the mass and brought out through the right nostril. It was then passed through the working channel of fibreoptic bronchoscope. The bronchoscope was advanced over guide wire and gradually guided below the mass and into vocal cords [Figure 2]. Once fibreoptic bronchoscope tip reached the point of entry of guide wire in trachea, the guide wire was removed and the bronchoscope was navigated distally into the trachea. Our patient was fairly comfortable during the procedure, secondary to adequately anaesthetised airway and we were constantly talking to him, as we advanced step-by-step.

Figure 2

Panel (a) depicts an oedematous mass occupying the supraglottic space, as seen with C-Mac© videolaryngoscope; followed by panel (b) with a view of the passing Terumo© urological J-tipped guide wire

Retrograde intubation, a technique developed in the 1960s by Butler and Cirillo, had been frequently used for difficult intubation prior to the advent of flexible fibreoptic bronchoscopy.[123] In patients, where a patent airway is not visible, passing fibreoptic bronchoscope blindly can lead to undue complications such as trauma, laryngospasm, bleeding and further worsening of an already compromised airway. Hence, by combining both techniques, the advantages afforded by both can be superimposed to our benefit. In the method described above, the J-tipped guide wire used is PTFE (Polytetrafluoroethylene) coated, which is kink-resistant and non-irritant to mucosal surfaces. After piercing the cricothyroid membrane, the flexible J-tip is directed upwards towards the glottis, allowing this thin (0.032 inch) wire to be negotiated via the narrowest available path with least resistance. In case any obstruction is encountered, the tip can be torqued to facilitate navigation into the larynx, while simultaneously visualising its entry from above by the fibreoptic bronchoscope.

Conventional[4] teaching dictates holding the catheter taut at both the entry and exit points during retrograde intubation. However, endotracheal tube or fibreoptic bronchoscope can abut[5] against the cricothyroid membrane hindering their smooth passage. Hence, we kept the guide wire lax, which proved very instrumental in advancing the fibreoptic bronchoscope into the trachea. The guide wire is easily available in urological theatres and due to its small size, it can be used with paediatric fibreoptic bronchoscope also. To conclude, the inclusion of retrograde intubation technique in difficult airway algorithm[6] underlines the importance of inculcating this time-tested skill, at trainee level.

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