DP18: AWAKE FIBEROPTIC INTUBATION IN AN 85-YEAR-OLD WITH LUDWIG'S ANGINA AND PREDICTED DIFFICULT AIRWAY
Brian Flores1; Sabrina Levin1; Alexa Flores2; Owen Katsikas3; Lorena Cal4; Melodie Dasr3; Giselle Wakim, MD1
1University of Miami Miller School of Medicine; 2University of Michigan; 3University of Florida; 4Miami Dade College
Introduction: Ludwig’s angina is a rapidly progressing cellulitis of the submandibular, sublingual, and submental spaces. For the anesthesiologist, it represents one of the most challenging airway scenarios due to the risk of sudden airway collapse, distorted anatomy, and the potential for a "cannot intubate, cannot ventilate" situation. We present the anesthetic management of an 85-year-old female requiring emergent incision and drainage (I&D) where a controlled, awake video laryngoscopy approach using a GlideScope was utilized to secure a tenuous airway.
Case Description: An 85-year-old female presented with severe sublingual and bilateral submandibular swelling following a mandibular dental implant procedure. Physical examination revealed "hot potato voice," significant trismus (MIO ~30mm), and a Mallampati III view. CT imaging confirmed a 7.1 x 6.1 x 7.1cm fluid collection extending from the submental region to the thyroid gland, consistent with Ludwig’s angina.
The anesthesia team opted for an awake intubation due to the high risk of airway collapse upon the induction of general anesthesia, which is primarily caused by the loss of pharyngeal muscle tone and posterior displacement of the tongue. The patient was pre-treated with glycopyrrolate and the airway was topicalized using nebulized 4% lidocaine, 2% lidocaine lollipops, and 2% lidocaine jelly applied directly to the GlideScope blade.
Under spontaneous ventilation and minimal sedation with dexmedetomidine, an awake GlideScope-assisted oral intubation was performed. Despite the anatomical distortion, the video laryngoscope provided a clear view of the glottic opening, and a size 6.5 cuffed endotracheal tube was successfully placed on the first attempt. General anesthesia was then induced. The patient underwent bilateral I&D and hardware removal. Post-operatively, she remained intubated for airway protection and was successfully extubated on POD 1 following a successful cuff leak test.
Discussion: While flexible fiberoptic intubation is traditionally considered the gold standard for awake airway management, this case highlights the efficacy of awake video laryngoscopy (AVL) using a GlideScope. AVL is a particularly valuable technique when the patient has sufficient mouth opening (MIO >20-25mm) to accommodate the blade.
In this case, the GlideScope stood out as a superior choice because it allowed for a wider, panoramic view of the distorted oropharyngeal anatomy, which can sometimes be difficult to navigate with a flexible scope in the presence of inflammatory debris or secretions. Furthermore, AVL allows the clinician to use a familiar intubation technique in a high-pressure environment while maintaining the safety of spontaneous ventilation. This approach successfully bypassed the risks of a standard rapid sequence induction, which is often contraindicated in Ludwig's angina due to the threat of total airway closure that cannot be rescued with bag-mask ventilation.
Conclusion: The successful management of this case demonstrates that awake video laryngoscopy is a safe and effective alternative to fiberoptic intubation for patients with Ludwig’s angina. When sufficient mouth opening is present, the GlideScope provides excellent visualization and reliable airway securement while preserving the patient’s respiratory drive and airway reflexes.