Worst-case scenario intubation of laryngeal granuloma: a case report
© Nakahira et al.; licensee BioMed Central Ltd. 2014
Received: 20 September 2013
Accepted: 2 February 2014
Published: 3 February 2014
Intubation of patients with laryngeal granulomas on the vocal folds are sometimes difficult to manage because of potential airway obstruction. Laryngeal granulomas usually have flexible stalks where they attach to the vocal folds. We report a worst-case scenario of dislocation of the laryngeal granuloma during induction of anaesthesia.
We present a case of laryngeal granulomas on the posterior vocal fold. A 20-year-old woman had an approximately 10-mm tumour in the laryngeal arytenoid region. Manual ventilation resulted in the tumour lodging in the subglottis and the inflated cuff of the intubation tube successfully returned it to its original position during tube withdrawal. Images were obtained using an Airway Scope® (Hoya-Pentax, Tokyo, Japan) and a video laryngoscope.
In our case, the tumour was benign and relatively small in size; therefore, we did not select tracheotomy as an airway management strategy. The case had a granulomatous tumour arising from the posterior vocal folds on the right side, and the tumour was very flexible. To promptly gain control of the airway in such a case using direct laryngoscopy, thus avoiding tracheotomy, other strategies are suggested, such as bronchoscopic visualization with awake or semi-awake intubation.
Intubation of patients with laryngeal granulomas on the vocal folds are sometimes difficult to manage because airway obstruction can occur. Laryngeal granulomas usually have flexible stalks where they attach and compared with polyps or laryngeal cancer, which are tightly attached to the larynx, intubation in patients with laryngeal granulomas must be performed carefully to avoid disrupting the tumour [1, 2]. Although there are several previous case reports of successful management of the difficult airway with laryngeal tumours, ours is the first report of dislocation of a laryngeal granuloma during treatment. We report a worst-case scenario of dislocation of a laryngeal granuloma during induction of anaesthesia. We used several imaging devices, including an Airway Scope® (Hoya-Pentax, Tokyo, Japan), a video laryngoscope.
The patient’s symptoms developed following general anaesthesia for dental extractions. Based on the clinical course of increasing frequency and duration of hoarseness, it was reasonable to presume that she had post-intubation granuloma. In this case, the location of the tumour changed after manual ventilation, becoming partially lodged in the glottis by the positive pressure ventilation. Therefore, ideally, awake or semi-awake intubation should have been performed. In cases with large or malignant tumours that can obstruct the glottis and trachea, tracheotomy can be performed, but the tumour was benign and relatively small in size in this case; therefore, we did not select tracheotomy as an airway management strategy. Also, tracheotomy is contraindicated in cases of laryngeal papilloma caused by human papillomavirus, which could not be ruled out preoperatively in this case .
Our case had granulomatous tumour arising from the posterior vocal folds on the right side, and the tumour was benign and very flexible. To promptly gain control of the airway in such a case using direct laryngoscopy, thus avoiding tracheotomy, other strategies are suggested. Awake or semi-awake intubation can be performed to prevent tumour disruption, and intubation can be performed by advancing the endotracheal tube along the opposite side from the tumour under bronchoscopic visualization. If the tracheal tube is advanced along the tumour side, the tumour becomes unobservable. Creative strategies, such as modifying the angle of the stylet, are necessary. In cases of dislocation and lodging of laryngeal tumours, the most appropriate device for visualization, such as a bronchoscope, should be prepared.
We report a worst-case scenario of dislocation of a laryngeal granuloma during induction of anaesthesia. Advanced devices should be equipped and creative strategies for each case are needed.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that no funding support was obtained for this study.
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