P061: AWAKE FIBEROPTIC INTUBATION IN THE SETTING OF PHARYNGEAL ABSCESS
Reena John1, Saniya Sami, MD1, Daniel Damtew, MD1, Javier Kaplan, MD2, Ryan Shienbaum, MD2; 1Kendall Regional Medical Center, 2Aventura Hospital and Medical Center
46 yo F presented for surgical incision and drainage of pharyngeal abscess.
VS: Tmax 101.6 F BP: 120/67 HR: 95 RR:18 O2%: 100 RA
GEN: AAO x 3, NAD
RESP: CTAB, no stridor noted
CVS: RRR NL S1S2
AIRWAY: Mallampati 3/4, thyromental distance > 3 finger breaths, limited ROM 2/2 pain
46 yo F presented for surgical incision and drainage of pharyngeal abscess. She presented with complaints of mouth and neck pain and difficulty in swallowing for 3 days, and had been spitting out saliva. On physical examination, she had no respiratory distress, but was uncomfortable because of pain and intra-oral drainage of pus. Pt was febrile on presentation. On airway examination mouth-opening was restricted, with an interincisor gap of 1 cm. There was a diffuse tender neck swelling, particularly in the sub-mandibular space. Neck extension was painful and limited. Both the nares were patent and the trachea was palpable in the lower part of neck
Awake fiberoptic intubation was planned, with tracheostomy as a backup. The procedure and need for awake nasal intubation was explained to the patient. She was premedicated with glycopyrrolate 0.4 mg. The base of the tongue and pharyngeal walls were anesthetized with lidocaine 4% Awake fiberoptic oral intubation in the seated position was initiated. After confirmation of tracheal intubation by fiberoptic viewing of tube tip inside the trachea and end-tidal carbon dioxide, she was sedated, anesthesized, and given muscle relaxant for immediate surgical incision and drainage. In the setting of airway edema, pt remained intubated and transferred to the ICU for close monitoring. She was extubated the following day. Post-extubation recovery was uneventful. The patient was discharged 2 days later.
Airway compromise has long been identified as cause of mortality in deep neck abscess.
Securing the airway in patients undergoing surgical intervention to control a deep neck infection (DNI) is challenging for anesthesiologists due to the distorted airway anatomy, limited mouth opening, tissue edema, and immobility.
It is critical to assess the risk of a potential difficult airway and prepare the most appropriate airway management method.
The management of DNI usually involves antibiotics or surgical drainage.
The induction of general anesthesia may precipitate complete airway closure.
Awake fiberoptic intubation has been recommended for managing difficult airway.
In experienced hands, awake fiberoptic intubation can be performed safely as the first choice to control the airway in adults with DNIs, and that tracheostomy is recommended if fiberoptic intubation is not available or has failed.