LETTER

Hippokratia 2015, 19(1):94

Tsaousi G, Pourzitaki Ch, Amaniti E
Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece

 

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Key words:  Airway management, awake intubation, epiglottic cyst, sevoflurane

Corresponding author: Pourzitaki Chryssa, Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece, e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Dear Editor,

Epiglottic cysts, although rare, may hinder tracheal intubation while the anesthetist may encounter difficulty in airway management1. We report the case of a 46-year-old male who underwent excision of a sizeable epiglottic cyst. His medical history included major depression combined with anxiety disorder, for which he was treated with a combination of sertraline with lorazepam. The patient refused to cooperate or consent to awake intubation under local anesthesia of the upper airway, so it was decided to proceed with induction to anesthesia with sevoflurane, using the technique of vital capacity breaths. When loss of consciousness was achieved, the sevoflurane concentration was reduced to 4% and its administration was continued for a total duration of eight minutes.After an extremely cautious direct laryngoscopy, Cormack and Lehane laryngoscopic view was graded as two. Dueto the cyst’s size, direct vision of the laryngeal entrance was not possible, so an elastic gum was inserted, in order to advance the cuffed sized 6.5 endotracheal tube (ETT) into the trachea. Following excision of the cyst, extubation was performedunder deep sedation in the operating room 15 minutes later, while no adverse events were encountered intraoperatively. Following a two-day uneventful postoperative period, he underwent indirect laryngoscopy, which revealed an edema-free epiglottis, so he was discharged from the hospital.

The preferable approach to secure the difficult airway is with the patient still awake, however in the reported case an alternative approach should be considered2.

The quality of induction with sevoflurane, along with its ability to generate optimal conditions for endotracheal tube insertion, without use of supplemental opioids or muscle relaxants, has been well documented3.Vital capacity breathing at 8% sevoflurane accelerates the induction to anesthesia and is associated with a lower incidence of involuntary movements and coughing.

The case reported herein further supports the fact that administration of neuromuscular blocking agents in a difficult airway scenario should be held back until proper position of endotracheal tube is verified3. Induction of anesthesia with high-concentrations of sevoflurane could be an attractive and safe alternative to standard general anesthesia approach for endotracheal intubation of patients with large epiglottic cysts, who refuse an awake intubation technique.

References

1. Kariya N, Nishi S, Minami W, Funao T, Mori M, Nishikawa K, et al. Airway problems related to laryngeal mask airway use associated with an undiagnosed epiglottic cyst. AnaesthIntensiveCare. 2004; 32: 268-270.
2. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al; American Society of Anesthesiologists Task Force on Management of the Difficult Airway.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: 251-270.
3. Wappler F, Frings DP, Scholz J, Mann V, Koch C, Schulte am Esch J. Inhalational induction of anaesthesia with 8% sevoflurane in children: conditions for endotracheal intubation and side-effects. Eur J Anaesthesiol. 2003; 20: 548-554.