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.