Critical Airway Management: Exploring a Complex Case of Awake Tracheotomy
Dario Winterton, MD, Stephen Odom, MD
Published December 2, 2024 | Clinics in Medical Education
Issue 4 | Volume 1 | November 2024
A 60 year old male presented with sore throat, fever, cough, and dyspnea and left neck swelling. Per chart review, patient had been feeling sick for a week. CT neck at community hospital was positive for abscess from left vallecula to left piriform and the patient received dose of unasyn, decadron, toradol, and racemic epi. The patient was transferred for specialized ENT care to the tertiary hospital. On arrival, the patient was noted to have breathing difficulty and inspiratory stridor.
Vital Signs:
- Temp: 98.3 °F (36.8 °C)
- Heart Rate: 85
- Resp: 20
- BP: 88/65
- SpO2: 96 %
- FiO2 (%):70 %
CT Scan
Abbreviated CT Report: Approximately 4 x 2 x 2 cm lobulated, peripherally enhancing hypodensity extending from the left vallecula caudally/posteriorly into the piriform sinus, with displacement of, mass effect upon, and pronounced narrowing of the supraglottic airway. There are several bilateral, borderline enlarged level 2 and 3 cervical lymph nodes.
In the context of the patient’s clinical presentation and the possible need for awake tracheostomy, the decision was made to proceed with an endoscopic exam in the Operating Room.
A flexible fiberoptic endoscopy was performed in the OR to assess the airway and evaluate for poten- tial awake fiberoptic intubation. The anatomy was completely distorted, with difficulty in identifying the airway.
A team decision was made to minimize airway manipulation and proceed to an awake surgical tracheostomy. Patient was consciously sedated with dexmedetomidine and low-dose remifentanil. Anesthe- sia was provided with abundant, multistep infiltration with lidocaine.
This patient had difficult anatomy with posteriorly oriented tracheal with minimal space from sternal notch and profound edema throughout the supraglottis and left posterior pharyngeal wall. An urgent awake tracheotomy (Bjork flap and stay sutures) and thyroid isthmusectomy was performed.
After the airway was secured, the patient was induced with midazolam and propofol and a laryngoscopy was performed
Laryngoscopy report
- Oropharynx: No mucosal lesions, masses, or erythema, tongue base without lesions. Thick secretions throughout.
- Hypopharynx: Edema of vallecula. No masses or lesions in vallecula, piriform sinuses, or post-cricoid area. Thick secretions throughout.
- Larynx: Epiglottis with watery edema on the left partially obstructing view of the vocal cords. No mass lesions.
Reasoning points: The decision to perform all procedures in the OR was taken so to have the best possible setup in case an emergent surgical intervention would have been required. Moreover, the low threshold to shift from awake fiberoptic endoscopy to awake tracheostomy was based on the patient still having a patent but extremely labile airway in the context of an extreme difficulty in identifying the airway on endoscopy, and thus avoiding any manipulation that might cause loss of ventilation capabilities.