Case Presentation
A 33-year-old woman, with severe postburn mentosternal contracture and cicatricial carcinoma, presented for skin grafting surgery in our hospital. The burn occurred when she was 4-year-old. She underwent two reconstructive procedures at 7 and 14 years in local medical centers. Due to the pain caused by the expansion of cicatricial carcinoma, affecting eating and speaking, she had tried several medical centers for treatment in the past year, but failed for unsuccessful ATI. In preoperative physical examination, severe scar contractures and a great tumor of approximately 15 cm×12 cm were observed on the lower lip, neck, and anterior chest (Fig. 1a and 1b); the chin, chest, and bilateral armpits fused together; the cervicomental and mentosternal angles completely obliterated; the anterior neck structures, including the larynx, the trachea, and the carotid arteries, were unidentifiable or impalpable. Mouth opening was limited (15 mm) and Mallampati test was unavailable. The left nostril was obstructive for stenosis, but the right nostril breathing was smooth. Preoperative X-rays and a computed tomography scan (data not shown) revealed distortion of the upper airway and no stenosis of the trachea. It was difficult to perform face mask ventilation because of the nearly fixed neck and regressed mandible. Meanwhile, conventional laryngoscopic intubation, laryngeal mask airway, lightwand, or a GlideScope Video laryngoscope were thought to be impossible. Moreover, surgical tracheostomy under local anesthesia [4] was not the preferred strategy for the existence of tumor on neck. Furthermore, the patient rejected ATI for discomfort and nociceptive recall before. Therefore, orotracheal or right nasotracheal fiberoptic intubation with sedation seems the last remaining strategy. Here we used intermittent sevoflurane inhalation for short sedation and modified SAYGO technique using flexible bronchoscopy for airway topicalization and nasotracheal intubation.
A written anesthetic consent was taken with explanation focused on the risks of difficult airway. Atropine 0.5 mg was intramuscular injected to reduce secretion before transferring to the operating room. The patient was monitored and preoxygenated once she arrived in the operation room. Vital signs were stable. A pillow and some folded sheets were stuffed between the patient back and the operating bed to make her feel comfortable. Intravenous midazolam 2 mg and sufentanil 5 μg were given. Nasal passage was anesthetized by pledgets with 2% lidocaine and 0.25% phenylephrine. Sevoflurane 2% with a flow rate of 4 L/min with 100% O2, was administered via an oxygen mask connected to the Y-piece of the ventilator circuit. The concentration of sevoflurane was gradually increased to 4% [5] and stopped when the bispectral index reached 55-60 within 3 minutes, then airway reassessment and topicalization were achieved by the modified SAYGO technique [6-8]. An epidural catheter (Fig. 2), with an outer diameter of 3.8 mm, was fixed and 1.5 cm longer was applied at the end of the fiberscope (MDH A10; Zhuhai Mindhao Medical Technology Co., Ltd., ShenZhen, China). Topicalization was achieved by spraying 2% lidocaine (7 ml) via the catheter onto the posterior nasal canal, pharyngeal cavity, epiglottis, glottis, and tracheal (Fig. 3). Meanwhile, supplemental oxygen 10 L/min was delivered by a hose (Fig. 2a) through the mouth to avoid hypoxemia. When lidocaine worked, about 5 minutes later, sevoflurane was inhaled again until the bispectral index reached 55-60. Then, a Parker Flex-Tip® tube with an inner diameter of 6.0 mm (Lead Medical Instrument Co., Ltd., Guangzhou, China), which was heated by 40 ℃ and lubricated in advance, was successfully and smoothly inserted into the trachea from the direction of flexible bronchoscopy (Fig. 1c). No stress reactions, including cough, hypertension, tachycardia, arrhythmia, hypoxia, and bronchospasm, and no intubation related complications, such as airway trauma, airway obstruction, and bleeding, were occurred during intubation. Importantly, the patient was very satisfied with this experience after emergence.