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Anaesthetic Management for a Large Epiglottic Cyst Excision
Manasi Ambardekar*, Anita Shetty**, Tanuja Sarang***, LV Dewoolkar+
Abstract
We present the anaesthetic management for excision of a large epiglottic cyst obstructing the airway. Conventional laryngoscopy and endotracheal intubation was difficult and potentially risky. Anticipating difficult airway, a decision was taken to perform an awake flexible fibreoptic intubation and was successfully managed.
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Introduction
Cysts of larynx may be congenital or
acquired. They may arise from the vocal cords (55%), ventricular bands (25%) or epiglottis (20%).1 Epiglottic cysts are rare and usually benign. During anaesthesia, they completely obstruct the view of larynx making laryngoscopy and intubation difficult. In the neonates, they can cause stridor and dyspnoea. Conventional tracheostomy has many inherent complications. The availability of flexible fibreoptic endoscope has provided an avenue to manage difficult airway.
Case Report
A 35-year-old male weighing 49 kg presented with difficulty in swallowing, change in voice and occasionally dyspnoea on exertion since 6 months. There was no respiratory obstruction in supine position.
External examination of the neck revealed a cystic swelling 3 cm x 2 cm on right side near hyoid bone. Examination of the oral cavity showed a globular cystic swelling arising from hypopharynx behind the tongue. On Indirect laryngoscopy, the vocal cords could not be visualized as cyst was filling the entire hypopharynx.
Mouth opening was adequate. Mallampatti score was Grade I. CT scan showed a cystic lesion 3.9 cm x 2.8 cm in the region of epiglottis, inferiorly extending into postero-superior part of hyoid bone.
Anticipating difficult airway, an awake fibre-optic intubation was planned. The patient was kept fasting for 10 hours pre-operatively. Informed consent for the procedure and emergency tracheostomy was taken. The upper airway was prepared as follows:
i. Premedication: Glycopyrrolate 0.2 mg intramuscularly
ii. Gargles with 2% Lignocaine viscous
iii. 4% Lignocaine nebulisation.
iv. Bilateral superior laryngeal nerve blocks
v. 2% Lignoadrenaline packs in both nostrils
vi. 4% Lignocaine transtracheal
A cuffed No.7.0 PVC endotracheal tube was threaded over a fibreoptic endoscope. Tip of the scope and tube were lubricated with 2% Lignocaine jelly. After preoxygenation with 100% oxygen, the scope was introduced through one of the nostrils and advanced. Initially, larynx was not visualized. It was very difficult to manipulate the endoscope. Rupture of the cyst had to be avoided. After many attempts, the laryngeal inlet was visualized. The scope was advanced till the carina was reached. The tracheal rings were identified. The endotracheal tube was now railroaded over the scope, passed through the vocal cords and placed in the trachea without rupturing the cyst. The endoscope was withdrawn and anaesthetic circuit attached. Bilaterally equal air entry was confirmed and tube secured. Anaesthesia was induced with Thiopentone 5 mg/kg-1 and Vecuronium 0.1 mg/kg –1. Midazolam 0.03 mg/kg-1 and Pentazocine 0.3 mg/kg-1 were given for sedation and analgesia respectively. Maintenance was with O2 : N2O (40:60) and Propofol infusion.
During the surgery, the cyst was inadvertently ruptured. The trachea was not soiled. The cyst walls were excised. It was arising from epiglottis. Surgery lasted for 1.5 hours. Blood loss was minimal.
Neuromuscular blockade was reversed using Glycopyrrolate 0.08 mg/kg-1 and Neostigmine 0.05 mg/kg-1. Trachea was extubated after confirming adequate recovery from neuromuscular blockade. Post-operative course was uneventful.
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| Fig. 1 Endoscopic view of the epiglottic cyst with endotracheal tube in situ |
Fig. 2 : Endoscopic view of the vocal 2 cords after excision of the cyst |
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Discussion
Whenever tracheal intubation by direct laryngoscopy is difficult or dangerous, fibreoptic endoscopy aided intubation is considered2. In our case, the airway was highly compromised. To induce general anaesthesia before securing the airway was risky. Options available were aspiration of the cyst pre-operatively, perform an elective tracheostomy or an awake fibreoptic intubation.
Aspiration of the cyst contents to improve the laryngeal view had the danger of soiling the pulmonary tree. These cysts can cause acute respiratory obstruction and pulmonary aspiration.3
Tracheostomy is associated with complications like bleeding, sub-cutanoues emphysema, pneumothorax, tracheomalacia, tracheal stenosis, etc.4
Two cases with different management were reported in 1987; one of which was aspirated and the other was intubated over a bougie.5
Taylor and Towey first introduced intubation by fibreoptic bronchoscope.6 When intubation is known to be either complicated or dangerous it offers several advantages. Time consuming and traumatizing attempts at intubation are avoided and the number of preoperative tracheostomies reduced.7 During induction, respiratory control is easily maintained, since intubation is accomplished with the patient in conscious state. If the patient is well informed and the upper airway adequately prepared, introduction of the bronchoscope is well tolerated. A glow seen from transillumination of larynx and trachea as the tip passes the glottis, confirms the position of the endoscope. This will not be seen if the scope is passed into the oesophagus.8
The problem in using fibreoptic laryngoscope under general anaesthesia is that the tongue falls back and visualization of vocal cords becomes difficult.9 So awake intubation is preferred.
Using nasal route in an awake patient requires skill in manipulating the endoscope past soft tissues, mucus, blood and limits the size of the endotracheal tube that can be passed. However, if passed orally, an awake patient can bite the endoscope and damage it.
Fibreoptic laryngoscopy can be used in difficult cases of obesity, short neck, maxillofacial deformities, temperomandibular ankylosis, cervical spondylosis, ankylosis and previous intubation problems.10
Thus, flexible fibreoptic laryngoscopy is a valuable method for endotracheal intubation of patients whose tracheas are difficult or impossible to intubate with conventional laryngoscopy.
Acknowledgements
We are thankful to the Dean and the Department of ENT, Seth GS Medical College and KEM Hospital, Mumbai for the support and cooperation extended to us for publishing this article.
References
1. Robin PE, Jan Olofsson. Tumors of the larynx. In John Hibbert editor. Scott brown’s Otolaryngology 6th edition Vol 5. Butterworth Heinemann International editions.
2. Stepen. N. Rogers, Jonathan L. Benumof. New and easy techniques for fibreoptic endoscopy-aided tracheal intubation. Anaesthesiology Dec 1983; 59 : 569-72.
3. McHugh P. Cyst of epiglottis. Anaesthesia 1989; 44 : 522.
4. John. V Donlon, Jr., D. John Doyle, Marc Allan Feldman. Anesthesia for eye, ear, nose and throat surgery. In Ronald D. Miller editor, Miller’s Anesthesia 6th edition Vol 2. Churchill Livingston.
5. Mason DG, Wark KJ. Unexpected difficult intubation. Anaesthesia. 1987; 42 : 407-10.
6. Taylor PA, Towey RM. The bronchofibrescope as an aid to endotracheal intubation. British Journal of Anaesthesia 1972; 44 : 611-2.
7. Messeter KH, Pettersson KI. Endotracheal intubation with the fibreoptic bronchoscope. Anaesthesia 1980; 35: 294-98.
8. P. Prithviraj Raj, John Forestner, Thomas. D. Watson, Richard E. Morris, M. T. Jenkins. Technics for fibreoptic laryngoscopy in Anesthesia. Anaesthesia and Analgesia 1974; 53 : 708-13.
9. Lloyd EL. Fibreoptic laryngoscopy for difficult intubation. Anesthesia 1980; 35 : 719.
10. Enje Th. Edens, Roberto L Sia. Flexible fibreoptic endoscopy in difficult intubations. Ann Otol 1981; 90 : 307-9. |
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AMOXYCILLIN FOR CAP - THREE DAYS, OR LONGER?
Stopping amoxycillin treatment after three days is no worse than stopping it after eight days in adults admitted to hospital with mild to moderate-severe community acquired pneumonia (CAP) who show substantial improvement after an initial three days of treatment. El Moussaoui and colleagues measured clinical and radiological success rates at day 10 and 28 in 119 patients who had been treated with intravenous amoxycillin for three days, then five days oral amoxycillin or placebo. The success rates were similar. A shorter treatment may help contain the growing resistance rates of respiratory pathogens.
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