Combined Use of a Gum Elastic Bougie and Video Laryngoscopy for Intubating a Patient With an Unexpected Laryngeal Papilloma

The incidence of previously undiagnosed laryngeal masses discovered during laryngoscopy reportedly ranges from 1 in 1250 to 1 in 4200.¹ Laryngeal masses are not easily discovered on routine preoperative examination since they are usually asymptomatic. However, displacement of a mass into the airway due to intubation maneuvers can have catastrophic consequences in an anesthetized patient. Previous reports have established the usefulness of video laryngoscopy while intubating patients with laryngeal masses.^2,3 In this case, a laryngeal mass was unexpectedly found during the initial intubation attempt with direct laryngoscopy. The patient was subsequently successfully intubated using a King Vision video laryngoscope (Ambu Inc, Bellerup, Denmark) along with a gum elastic bougie (GEB). The patient provided written informed consent for publication of this report.

CASE PRESENTATION

A 75-year-old male patient (height 167 cm, weight 65 kg, body mass index 23.3 kg/m²) was scheduled for apical resection and cystectomy for periapical cysts of the maxillary central incisors under intubated general anesthesia. The patient had a history of schizophrenia, asbestosis of the lungs, and insomnia. He reported taking ramelteon and haloperidol regularly and denied any allergies. No abnormalities were revealed during routine preoperative testing, which included a 12-lead electrocardiogram, a basic metabolic panel, an anteroposterior (AP) chest radiograph, and an orthopantomogram. Routine preoperative physical examinations did not reveal any indications of a difficult airway or intubation.

General anesthesia was induced intravenously with a continuous infusion of remifentanil (0.3 μg/kg/min) and boluses of propofol (70 mg) and rocuronium (50 mg), after which mask ventilation was performed without any issue. A mass at the right side of the glottis was detected during direct laryngoscopy using a #3 size Mackintosh blade (Figure 1). The traditional laryngoscope was switched out for a video laryngoscope with channeled blade (King Vision, Ambu Inc) to better assess the mass, revealing a pedunculated tumor approximately 10 mm × 10 mm in size located along the right side of glottis. The soft-tissue mass initially appeared to be cystic in nature because of its round shape, and its size and location hampered insertion of a standard oral endotracheal tube (ETT; Figure 2). Thus, we decided to use a GEB to bypass the mass and help facilitate easy passage of the ETT. The GEB was gently advanced through the glottic opening, beyond the vocal cords, and into the upper trachea. While stabilizing the GEB, an 8.0-mm standard oral ETT was advanced down the length of the GEB, and the patient was smoothly intubated, all under the guidance of video laryngoscopy (Figure 3). SpO₂ remained within normal limits throughout induction. Anesthesia was maintained with sevoflurane (1.5–2.0%), O₂ (1 L/min), and air (2 L/min), along with a continuous infusion of remifentanil (0.3 μg/kg/min). The total surgical time was 1 hour. After confirming that the mass was not ruptured or damaged, the patient was extubated awake without difficulty. The patient had no complications during recovery or after returning to the ward, where he was carefully monitored. He was discharged 5 days after surgery, at which time a consultation with an otolaryngologist was recommended for evaluation of the laryngeal mass. The laryngeal mass was removed 2 months later and diagnosed histopathologically as a laryngeal papilloma.

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DISCUSSION

In symptomatic patients, the signs and symptoms of laryngeal masses may include voice changes, stridor, or pharyngeal discomfort. However, in this case, the patient was asymptomatic, and the mass was not revealed during preoperative imaging such as the panoramic or AP chest radiographs. Laryngeal masses have reportedly caused airway obstruction after being pushed, displaced, and even completely avulsed into the airway during intubation as a result of rough handling of the ETT and not using a careful, gentle approach. Moreover, blind insertion of an ETT can cause inadvertent injury to the mass as well as the normal airway anatomy. Although most laryngeal masses are asymptomatic, they can cause airway embarrassment, potentially leading to catastrophic consequences for a patient in the perioperative period. If such an event occurs, the immediate establishment of a surgical airway (eg, tracheostomy or cricothyrotomy) is likely indicated. However, these procedures may be ineffective in reestablishing patency and securing the airway if the obstruction occurs in the lower aspect of the trachea.

In this case, we were fortunate to initially detect the laryngeal mass during direct laryngoscopy and confirm its location relative to the glottis using a video laryngoscope without traumatizing the mass. However, its size and location effectively prevented the oral ETT from being easily advanced into the trachea without significant risk for additional complications (ie, hemorrhage, dislodging/avulsing the mass, etc). Therefore, a GEB was used to help atraumatic passage of the ETT. A GEB is useful for difficult intubation cases, especially in situations in which the ETT is difficult to manipulate and orient spatially. The GEB is an easy-to-use, portable, and relatively inexpensive intubation aid. Furthermore, the American Society of Anesthesiologists' practice guidelines for the management of a difficult airway also include the use of a GEB for securing a difficult airway.⁴ Although a flexible fiber-optic bronchoscope can also be used for the management of difficult airways, it can be very challenging to maneuver the fiber-optic scope around a mass. In fact, a previous study found a GEB to be superior to a flexible fiber-optic scope for difficult airway intubation.⁵ However, it must be appreciated that use of a GEB does require identification of the glottic opening; otherwise, substantial trauma to the airway can result. Use of a flexible fiber-optic bronchoscope is advised in circumstances in which the glottic opening cannot be readily identified.

Although GEBs can be used routinely for easing intubations, there are several factors that should be taken into consideration. Preformed oral and nasal Ring-Adair-Elwyn (RAE) endotracheal tubes are often used in dental and oral surgery cases because they can provide improved access and minimize the obstructed view of the surgical field. However, the routine use of GEB with RAE tubes is not generally recommended as the first line of treatment because of the risks of tracheal trauma/mucosal tearing as a result of difficult advancement or accidental malpositioning that may occur due to the curvature of the RAE tubes.⁶ In addition, the GEB tip should always be visualized as it passes the vocal cords during insertion, as blind insertion of GEBs has led to lacerations of the trachea and pharynx in several cases.^7–9 GEBs can be successfully inserted under direct laryngoscopy; however, video laryngoscopy can provide a clearer image of the airway, making manipulation and passage of the GEB and ETT easier and safer. Therefore, video laryngoscopy is a recommended adjunct for improving visualization during insertion of a GEB and intubation.

CONCLUSION

A GEB is a useful aid for facilitating passage of an ETT when unexpected intubating difficulties arise. However, blind GEB insertion may result in airway injury and should be avoided. Combining the use of video laryngoscopy with a GEB can be helpful when managing a difficult airway, such as when intubating a patient with an unexpected laryngeal mass, without causing accidental airway trauma.