CASE REPORT:

50 years old male, known case of type 2 Diabetes mellitus presented to ER with complaint of swelling of left side of face along with left periorbital edema, gradually progressing over 1 week. History of fever for 2 days.

CT neck and facial bone– Ill-defined soft tissue edema and Inflammatory fat stranding in left parotid, para-pharyngeal, submandibular, masticator space (altogether measuring 7.5 ×7cm), extending upto the level of pharyngeal mucosa space on the left side at the level of oropharynx with associated airway luminal narrowing. Multi-compartmental cellulitis.

Plan– Exploration, Incision and drainage of left large suppurative parotitis.

Lab Investigations– Hb-16.3g/dl; WBC-26,500 cells/cmm; S.Creatinine-1.33mg/dl ; INR-1.2; RBS-200mg/dl

ECG– Sinus Rhythm, Qs with ST coving- Lead III, avf

Echo– Lvef-62%, No RWMA, No PAH. TROP I– Negative

Airway assessment:

• Mouth opening: 1 Finger breadth (Restricted)
• Mallampatti Grade: cannot be assessed

ENT Opinion-Mouth opening restricted. Swelling- left side soft palate, left tonsillar region extending to left para-pharyngeal region.

Indirect Laryngoscopy– B/L vocal cord normal & mobile , Airway adequate below the level of epiglottis, Airway narrowing at the level of oropharynx. Advised Inj. DEXAMETHASONE 8mg IV stat.

Cardiologist opinion- High cardiac risk for planned procedure.

Anaesthesia Concern– Anticipated Difficult Airway, Plan- AWAKE FIBREOPTIC INTUBATION with Upper airway block

PRE-OPERATIVE PLANNING:

• The anesthesia plan and its associated risks were thoroughly discussed with the surgeon, and the information was clearly conveyed to the patient and their attenders. Informed and written consent was obtained.
• The availability of ENT Surgeon in the vicinity has been confirmed.
• NPO status was confirmed and adequate.
• Premedication such as Inj. PANTOPRAZOLE 40mg IV, Inj. PALONOSETRON 0.075mg IV stat given. IV fluid Ringer lactate at 100ml/hr.
• Oxymetazoline  hydrochloride(0.05%) nasal drops ( 2 drops) were administered in both nostrils 30 mins prior to upper airway block.
• All necessary resuscitation equipments were prepared and readily available.

INTRA-OPERATIVE MANAGEMENT:

• ASA- Standard monitors were placed on the patient. Vitals were monitored throughout the surgery.
• Oxygen was administered at a rate of 4L/min through the opposite nostril using a nasal cannula.
• GLYCOPYROLATE 0.2mg IV, Inj. FENTANYL 1mcg/kg IV given to reduce secretion and pain respectively. Antibiotic Inj. MEROPENEM 1g IV ( day2) given.
• Bilateral Superior laryngeal nerve and recurrent laryngeal nerve block given.
• Superior laryngeal nerve block: The hyoid is gently displaced to the side where the block will be performed, and a 25G needle is inserted laterally into the neck, aiming towards the greater cornu. Once contact is made, the needle is moved inferior off the bone and 2ml of 2% Lidocaine on each side is injected.

• Recurrent laryngeal nerve block: One hand should stabilize the trachea at the level of the Thyroid cartilage using the thumb and third digit. A 20G or 22G needle is then inserted perpendicular to the skin, aiming to penetrate the cricothyroid membrane, located above the cricoid cartilage. Continuous aspiration should be performed during this process, as the appearance of bubbles will indicate that the needle tip has entered the trachea. once this occurs, immediately stop advancing the needle to avoid puncturing the posterior laryngeal wall. Rapidly inject 4ml of 4% Lidocaine, followed by removal of the needle.This will likely induce coughing, which helps to distribute the local anaesthetic and block the recurrent laryngeal nerve.

• Communication with the patient during the procedure is essential.
• AWAKE FIBREOPTIC INTUBATION done.
• AWAKE FIBREOPTIC INTUBATION– Lubricate both the tip of the endotracheal tube (ETT) and the fibrescope to ensure smooth passage. Insert the fibrescope through the nostril and directing it into the lower nasal meatus, which is the largest and inferior part.We can see the nasal septum medially, the floor of the nose superiorly, and the turbinate laterally. After passing through the nasal septum, move the fibrescope into the nasopharynx. Guide the scope further into the oropharynx, where we may need to gently separate the soft palate from the posterior pharyngeal wall. As we reach the oropharynx, the epiglottis will be the first landmark we encounter. Continue advancing the fibrescope into the laryngeal opening, at which point we will need to administer a topical anaesthetic. Inform the patient that they may feel the need to cough. Allow a few minutes for the anaesthetic to take effect. Next, move the fibrescope into the subglottic space, identifying the trachea as the second landmark. Apply the second dose of local anaesthetic, which may also cause coughing. Retract the scope slightly, just before the laryngeal opening, and then advance it into the trachea, identifying the carina as the third landmark. At this point, ask the assistant to hold the fibrescope steady while  proceeding with intubation. Gently rotate and advance the ETT through the nose, nasopharynx, oropharynx, and larynx until it is correctly positioned.
• Keep the carina in view at all times to prevent the fibrescope from shifting into the oesophagus. While withdrawing the fibrescope, ensure the tip of the endotracheal tube (ETT) remains in the trachea, positioned about 3-5 cm above the carina. After confirmation, secure the ETT in place and attach it to the anaesthetic breathing circuit. Confirm proper ETT placement by checking capnography, listening for bilateral air entry, observing chest movement on both sides, noting misting in the tube, and feeling air movement at the tube’s tip.

• Hemodynamically stable throughout the surgery.
• Patient shifted to ICU for Elective Postoperative Ventilation for a day.

POST-OPERATIVE PERIOD:

Patient was Extubated on POD-1. Hemodynamically stable.

DISCUSSION:

The American Society of Anesthesiologists Task Force defines a difficult airway as a clinical scenario where the anesthetist faces challenges with facemask ventilation, supraglottic device ventilation, tracheal intubation, or any combination of these. Alternatively, a difficult airway is described as a situation where direct laryngoscopy requires more than two intubation attempts with the same or a different blade, the use of adjuncts to direct laryngoscopy, or the need for an alternative device or technique after a failed direct laryngoscopy intubation. Difficult laryngoscopy is indicated by a Cormack and Lehane Grade 3 or 4 laryngeal view.

         Awake fiberoptic intubation (AFOI) is an essential technique for managing patients with known difficult airways—those who have previously required AFOI or other specialized procedures and adjuncts beyond standard airway management—or for those with anticipated difficult airways identified during preoperative assessment. This method involves using a flexible oral or nasal approach to visually locate the vocal cords, enabling the accurate placement of an endotracheal tube into the trachea under direct visualization.

REFERENCES:

1. Sanchez A, Iyer RR, Morrison DE. Preparation of the patient for awake intubation. In: Hagberg CA, editor. Benumof’s Airway Management: Principles and Practice. Philadelphia: Mosby-Elsevier; 2007. pp. 255–80.
2.  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. 2003;98:1269–77. doi: 10.1097/00000542-200305000-00032.
3. Rosenblatt WH, Sukhupragarn W. Airway management. In: Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, editors. Clinical Anesthesia. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2009. pp. 751–92.

Dr Hemalatha Iyanar,
Senior Consultant,
Department of Anaesthesiology,
Kauvery Hospital, Chennai.

Dr Moushiga Subhashini,
II Year DNB Resident,
Department of Anaesthesiology,
Kauvery Hospital, Chennai.