Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 3  |  Page : 450-452

Anticipated difficult intubation due to intraoral lipomatous polyp


Department of Anesthesiology and Critical Care Medicine, ENT, Manvi Home Ahead Shyamal Hospital, Patna, Bihar, India

Date of Submission02-Jan-2015
Date of Acceptance04-May-2015
Date of Web Publication29-Jul-2015

Correspondence Address:
Neeraj Kumar
Manvi Home Ahead Shyamal Hospital, Urja Gram, Khazpura, Patna - 800 014, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.158999

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  Abstract 

Anticipated difficult intubation if not planned meticulously can be challenging to a anesthesiologist. We describe a successful management of a case of anticipated difficult intubation due to a rare intra oral lipomatous polyp arising from the posterior pharyngeal wall. We use levering McCoy laryngoscope for intuabting trachea because we failed to intubate with conventional MacIntosh laryngoscope in first attempt and for fear of complete airway obstruction dexmedetomidine infusion was used for sedation. In our case we relied on radiological imaging for assessment of difficult airways. So managing each case is highly unique, individualized and no technique is obsolete in managing difficult airways even with a unavailability of modern aids.

Keywords: difficult intubation, McCoy polariscope, intra oral diplomats polyp


How to cite this article:
Kumar N, Bhardwaj G, Singh RK. Anticipated difficult intubation due to intraoral lipomatous polyp . Ain-Shams J Anaesthesiol 2015;8:450-2

How to cite this URL:
Kumar N, Bhardwaj G, Singh RK. Anticipated difficult intubation due to intraoral lipomatous polyp . Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2019 Sep 20];8:450-2. Available from: http://www.asja.eg.net/text.asp?2015/8/3/450/158999


  Introduction Top


Intraoral benign polyploidal tumor may present as a lipomatous polyp, and benign mucosal neoplasm represents 1-4% of all benign tumors involved in the oral cavity [1],[2],[3] . They are slow-growing, well-circumscribed, painless soft tissue tumors that may be superficially or more deeply located, but has a malignant counterpart called liposarcoma [1],[2],[3] . The most frequent sites of presentation are buccal mucosa, lips, tongue, palate, buccal sulcus, and floor of the mouth. We present the case report of a patient with intraoral lipomatous polyp diagnosed on computed tomography and further confirmed on histopathological examination.

The management of anticipated difficult intubation is unique and individualized to each case. Here, we report a case of anticipated difficult intubation of a intraoral lipomatous polyp arising from the posterior pharyngeal wall abutting the posterior surface of the tongue in which dexmedetomidine infusion was used for sedation followed by the orotracheal technique aided with gum elastic bougie for intubation.


  Case report Top


A 19-year-old female presented with a long history of dysphagia, anorexia, and weight loss. She had also a 2-week history of shortness of breath on exertion and associated dysphonia. The excision of a intraoral lipomatous polyp under general anesthesia was planned. Her routine investigations were within normal range. The airway [Figure 1] showed a pedunculated intraoral lipomatous polyp hanging in the oropharynx and obstructing the oral cavity on a computed tomography scan. Airway examination showed full mouth opening with adequate neck extension of Mallampati grading II. Nasal septum deviation was seen to the left. A computed tomography revealed that the tumor was slightly obstructing the nasopharynx and that the oropharyngeal lumen was compromised [Figure 2]. Because of the concern on the possibility of a compromised airway and difficult intubation, we informed the patient of the necessity of performing an emergency tracheostomy. Written informed consent was taken as per the routine protocol with difficult airway cart kept ready. A standard routine monitoring such as ECG, noninvasive blood pressure, and pulse oximetry were used. Glycopyrrolate (0.2 mg) was used as premedication and fentanyl (2 μg/kg) was administered. As face mask ventilation was adequate, an inhalational induction was planned with upward titration of 1-8% sevoflurane in 100% oxygen and spontaneous ventilation was maintained.
Figure 1: Arrow showing intra oral lipomatous polyp.

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Figure 2: Computed tomography scan of the nasopharynx and oropharynx.

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Anesthesia was maintained with dexmedetomidine (50 μg) infused over 10 min, and the patient was under continuous monitoring as there was an increased risk for excessive sedation leading to airway compromise. After placing the patient in a sniffing position, first we performed laryngoscopy with MacIntosh blade 3 and it was difficult to visualize the epiglottis, and we then used a McCoy laryngoscope and it was possible to pass distal to the pedunculated lipomatous polyp, displacing it to one side and allowing visualization of the vocal cords. The endotracheal intubation was completed with the help of gum elastic bougie. Thereafter, tracheal cuff was inflated and tube placement was confirmed by bilateral air entry on chest auscultation and capnography, followed by vecuronium for neuromuscular blockade. Definitive treatment was aspiration of thick pus, followed by excision. The intraoperative period of surgery and anesthesia was uneventful. Microbiological culture grew Pseudomonas aeruginosa. Histological examination revealed a benign lipomatous polyp and it was treated with intravenous antibiotics. The patient was discharged on fifth day postoperatively.


  Discussion Top


Difficult tracheal intubation accounted for ~17% of adverse respiratory events for surgical patients in a closed-claims analysis, executed by the American Society of Anesthesiologists [4] . On the basis of the intubation difficulty scale, our patient did not actually fulfill many criteria of difficult intubation, such as inadequate mouth opening, limited neck extension, or unfavorable degree of Mallampati classification [5] . Therefore, we considered that conventional direct laryngoscopy may be feasible if the mask ventilation was secured [5] . A lipomatous polyp was anchored to the laryngeal structure on the neighboring connective tissue due to soft tissue stiffness. Hence, in our patient, an alternative method using a levering laryngoscope was chosen in view of distorted laryngeal anatomy. A fiberoptic intubation with a flexible fiberoptic bronchoscope is the gold standard for an anticipated difficult intubation, especially when complicated with a compromised airway [6],[7],[8] .

Therefore, even in an institute lacking a fiberoptic bronchoscope, a similar type of intraoral lipomatous polyp can be managed successfully as in our case, and we relied on radiological imaging, which proved to be a useful tool in the assessment of difficult airways. In our case, we were aware of the potential airway difficulty, and so supraglottic airway devices and cricothyroid and retrograde intubation were set up apart from emergency tracheostomy, but as face mask ventilation was possible we have easily performed intubation in the second attempt with the help of gum elastic bougie and a McCoy laryngoscope. A nasotracheal intubation was avoided for the fear of rupturing the cyst and potential aspiration of the cyst content due to deviated nasal septum and the slight obstruction of the nasopharynx confirmed on computed tomography. The McCoy levering laryngoscope has been well recognized as a useful tool for certain cases of difficult intubation [9],[10] . Using an inhalation induction along with dexmedetomidine as infusion for sedation, we were able to maintain spontaneous breathing in our patient, enabling us to safely secure the airway without compromise. We relied on the advantages of the levering laryngoscope, as it improves the direct vision of the larynx and expands the laryngeal aperture room when regular laryngoscopic forces could not elevate the epiglottis anymore. It has been proven to be safe on the basis of our radiological assessment using computerized tomography. If newer or modern aids are not available, as in our case, no technique is obsolete in the management of anticipated difficult airways. This case reinforces the need for avoiding repeated intubation attempts, which may further increase complications, and also reinforces the requirement for an ENT surgeon being immediately available to safely secure the airway in such a setting, which is highly beneficial. Therefore, with this case we would like to state that, if an institute does not have a newer or modern aid such as a fiberoptic bronchoscope, such cases can be managed successfully with an individualized approach.


  Acknowledgements Top


Manuscript has been read and approved by all authors, the requirements for authorship have been met, and each author believes that the manuscript represents honest work.

Conflicts of interest

None declared.

 
  References Top

1.
De Visscher JG. Lipomas and fibrolipomas of the oral cavity. J Maxillofac Surg 1982; 10:177-181.  Back to cited text no. 1
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2.
Gnepp DR, ed. Diagnostic surgical pathology of the head and neck. 2nd ed. Philadelphia, PA: Saunders; 2009.  Back to cited text no. 2
    
3.
Weiss SW, Goldblum JR. Benign hipomatous tumors. In: Weiss SW, Goldblum JR, Enzinger FM, eds. Enzinger and Weiss's soft tissue tumors. 4th ed. St Louis, MO: Mosby; 2001:571-639.  Back to cited text no. 3
    
4.
Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology 1990; 72:828-833.  Back to cited text no. 4
    
5.
Adnet F, Borron SW, Racine SX, Clemessy JL, Fournier JL, Plaisance P, Lapandry C. The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology 1997; 87:1290-1297.  Back to cited text no. 5
    
6.
Thierbach AR, Werner C. Infraglottic airway devices and techniques. Best Pract Res Clin Anaesthesiol 2005; 19:595-609.  Back to cited text no. 6
    
7.
Dabbagh A, Mobasseri N, Elyasi H, Gharaei B, Fathololumi M, Ghasemi M, Chamkhale IB A rapidly enlarging neck mass: the role of the sitting position in fiberoptic bronchoscopy for difficult intubation. Anesth Analg 2008; 107:1627-1629.  Back to cited text no. 7
    
8.
Ovassapian A. Fiberoptic endoscopy and the difficult airway. 2nd ed. Philadelphia, PA: Lippincott-Raven Press; 1996.  Back to cited text no. 8
    
9.
Tuckey JP, Cook TM, Render CA. Forum. An evaluation of the levering laryngoscope. Anaesthesia 1996; 51:71-73.  Back to cited text no. 9
    
10.
Aoyama K, Nagaoka E, Takenaka I, Kadoya T. The McCoy laryngoscope expands the laryngeal aperture in patients with difficult intubation. Anesthesiology 2000; 92:1855-1856.  Back to cited text no. 10
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