2024 FSA Podium and Poster Abstracts
P094: DIFFICULT INTUBATION DUE TO LARGE ANTERIOR CERVICAL OSTEOPHYTES IN A CARDIAC PATIENT
Adryan Perez, MD; Oscar Aljure, MD; Pankaj Jain, MD; University of Miami Miller School of Medicine
Introduction: The incidence of difficult intubation is higher in patients undergoing cardiac surgery [1]. Multiple and prolonged attempts at securing the airway may have adverse hemodynamic consequences, which may be especially harmful in the cardiac patient population [2]. Additionally, patients with pulmonary hypertension are at further risk of hemodynamic instability due to worsening right ventricular afterload [3]. Anterior cervical osteophytes are a rare cause of unanticipated difficult airway if unrecognized. We report the case of a difficult intubation attributed to cervical osteophytes in a patient with severe valvulopathy and pulmonary artery (PA) hypertension.
Case Presentation: A 68-year-old male, ASA status 4 patient with normal biventricular function, severe aortic and mitral regurgitation, and a baseline systolic PA pressure of 82 mmHg presented for minimally invasive aortic and mitral valve replacement. The patient endorsed symptoms of dysphagia, and a CT of the neck and soft tissues demonstrated large anterior osteophytes (Figure 1) extending from C2 to T1 vertebral bodies, resulting in anterior displacement of the laryngopharynx and medial deviation of the right vocal cord. An outpatient ENT fiberoptic laryngoscopic exam report revealed a diffusely protruding posterior pharyngeal wall to the level of the epiglottis. Airway exam was pertinent for a thyromental distance of 2 fingerbreadths, visible anterior protrusion of the thyroid cartilage, and a bulge in the posterior pharyngeal wall. Availability of airway equipment was ensured. After pre-oxygenation, general anesthesia was induced, and bag-mask ventilation was easily accomplished. Following adequate neuromuscular blockade, video laryngoscopy was performed with limited visualization of the posterior vocal cords and arytenoids. An 8.0 mm internal diameter (ID) endotracheal tube over a preformed rigid stylet could not be advanced across the glottic inlet due to deviation caused by the protruding hypopharynx. A second attempt by more experienced anesthesiologists with a combined fiberoptic and video laryngoscopic approach was also unsuccessful due to the inability to approximate the fiberoptic tip to the glottic opening. Successful intubation was finally achieved with a 7.0 mm ID endotracheal tube over a malleable stylet with acute distal angulation, using the videolaryngoscopy alone. Mask ventilation was not compromised between attempts, and no significant hemodynamic changes or hypoxemia were experienced. A pediatric transesophageal echocardiographic probe was selected and easily inserted. After surgery, the patient was uneventfully extubated in the intensive care unit the following morning.
Figure 1: CT Neck demonstrating Large Anterior Osteophytes
Discussion: Anterior cervical osteophytes may result in anterior displacement of the larynx and narrowing of the hypopharynx. These are a rare cause of difficult airways and complications related to TEE probe insertion. Preoperative review of airway imaging, detailed patient history, and careful airway assessment can help distinguish ‘difficult’ airway anatomies. Pre-operative planning, especially in the context of the cardiac patient's impaired cardiopulmonary physiology, is paramount to minimizing potential respiratory and hemodynamic compromise.
References:
[1] Are cardiac surgical patients at increased risk of difficult intubation? Indian J Anaesth. 2017;61:629-635.
[2] Airway management of the cardiac surgical patients: Current perspective. Ann Card Anaesth. 2017;20:S26-S35.
[3] Advanced airway management and respiratory care in decompensated pulmonary hypertension. Heart Fail Rev. 2022;27:1807-1817.