Prevertebral abscess and airway obstruction.

Sir,

A 45-year-old man presented with a history of neck pain of 10 days duration, low-grade fever and weakness of limbs of 1 week duration, and difficulty in swallowing and breathing in the supine position of 2 days duration. On examination, he was conscious with power of 4/5 in all limbs and room air saturation of 96% in propped-up position. Except for elevated leukocyte count, rest of laboratory parameters were normal. Magnetic resonance imaging (MRI) of the cervical spine revealed prevertebral collection from C2 to C5, causing airway compression [Figure 1a–c]. Spinal cord compression was seen at C3–C6 level. He was scheduled for emergency drainage of prevertebral abscess. His preoperative medications included antibiotics and steroids.

Figure 1

(a) Magnetic resonance imaging of the cervical spine and neck showing prevertebral collection with associated narrowing of the airway and minimal compression of the cervical spinal cord at C3–C6 level. (b) Axial view demonstrating significant narrowing of the airway at C3 level due to prevertebral collection. (c) Axial view demonstrating significant narrowing of the airway at C3–C4 level due to prevertebral collection

In the operation theater, standard monitoring was connected and the patient was continued in the propped-up position with oxygen 2 L/min via a nasal cannula. Glycopyrrolate was administered to reduce secretions. The patient was explained about awake fiberoptic oral intubation technique in view of airway compromise. Airway anesthesia was achieved using topical 2% lignocaine and bilateral superior laryngeal nerve block and transtracheal injection. As upper airway was narrowed, 4 mm outer diameter pediatric intubating scope was used to railroad 6.5 mm inner diameter tracheal tube into the trachea. Following confirmation of correct tube placement, anesthesia was administered. Following uneventful surgery, in view of possible airway edema from surgery and preexisting airway compromise, the patient was electively ventilated for 24 h and later extubated. Rest of the hospital course was uneventful. The microbiological examination of the pus revealed methicillin-resistant Staphylococcus aureus sensitive to vancomycin.

The difficult airway algorithm in the American Society of Anesthesiologists guidelines details the strategies that have to be employed in anticipated difficult airway.[1] We anticipated difficult mask ventilation and intubation. Placement of supraglottic airway devices was not an option in this patient. After weighing the available airway management options, we decided on awake fiberoptic intubation in discussion with the patient, in which we succeeded. If this option was not available, our backup plan was to secure the airway awake using direct laryngoscopy. The choice of a smaller size tube was based on the airway dimension that we measured on axial MRI images due to tracheal compression from the abscess. This facilitated placement of tracheal tube without causing damage/rupture of the abscess which might have spoiled the airway leading to aspiration pneumonia. This possibility existed as airway was anesthetized with suppression of cough despite patient remaining awake throughout intubation procedure. If anesthesia was induced, there was inherent risk of complete obstruction of the airway causing “cannot ventilation” situation.

A previous case report describing airway management in an infant with retropharyngeal abscess reported loss of airway during airway management under sevoflurane anesthesia.[2] Intubation attempts with normal size tubes in a potentially difficult airway can lead to complications and should be avoided.[3]

To conclude, airway management in patients with retropharyngeal/prevertebral abscess is challenging requiring careful preparation and alternative plans for securing the airway in place. The preferable choice is securing the airway awake using fiberoptic scope as done in this case.

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