Tongue depressor as an intubation aid in a patient with vallecular cyst : A case report

Journal of Anaesthesia and Critical Care Case Reports 2018 Jan-Apr;4(1):16-18 1 Depar tment of Anaesthesiolog y, Aga Khan University Hospital 2 Depar tment of Anaesthesiolog y, Aga Khan University Hospital Department of Surgery, Aga Khan University Hospital Address of Correspondence Dr. Dr. Abdul Monem, Department of Anaesthesiology, Aga Khan University E-mail: abdul.monem@aku.edu © 2018 by Journal of Anaesthesia and Critical Care Case Reports| Available on www.jaccr.com | This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Journal of Anaesthesia and Critical Care Case Reports Volume 4 Issue 1 Jan-Apr 2018 Page 16-18 16 | | | | | Dr. Abdul Monem Dr. Fauzia Anis Khan Dr. Sohail Awan 5).Patient’s trachea was extubated after insertion of a nasogastric tube. Her postoperative recovery was uneventful and she was discharged 2 days later. Biopsy reported the specimen to be a lipoma. Discussion Congenital laryngeal cysts are rare, with an incidence of 1.82 per 100,000 live births [1]. Common sites are 58.2% in the glottic area and 18.3% in the ventricular folds. The remainder waslocated on the aryepiglottic fold (2.2%) and interarytenoid region (0.7%) [2]. These are benign and do not usually cause problems, but unidentified cases are very prone to sudden severe hypoxia and death due to complete airway collapse,especially in children. Adults may present with symptoms of change in voice or dysphagia. Laryngocele and saccular cysts are also rare cause of such symptoms. Laryngoceles cause episodic symptoms as theyintermittently fill with air, whereas saccular cysts cause constant symptoms. Children usually present with difficulty in breathing, swallowing, and failure to thrive. Yadav [3] reported hemoptysis as a presenting symptom. Trauma and cyst rupture may lead to aspiration during intubation. Mason and Wark[4] reported two cases of difficult mask ventilation after intravenous induction. Both were found to have vallecularcyst obscuring the glottis view on laryngoscopy. One was intubated after successful aspiration of the cyst by the ENT surgeon. Other was intubated with the help of a bougie. McHugh [5] also reported successful intubation with the help of a bougie in an unexpected case of a large epiglottic cyst. Different methods of airway maintenance have been reported in the anesthetic management of these cases. McKiernan [6] reported blind intubation in a 7-year-old child with the help of smaller tube with double bend on a malleable introducer by pushing an unexpected vallecular cyst to one side. Awake fiber-optic intubation is considered the safest technique in difficult airway management, but this technique may be associated with difficulty to negotiate around the cyst. It may also cause rupture of cyst or traumatic bleed leading to aspiration. Inspite of these disadvantages, it has been successfully used in infants [7]. Ahrenset al. [8] reported intubation of a 3-month-old child with a 2.2 fiber-optic bronchoscope through a laryngeal mask airway. Remifentanil and propofol sedation has been used for fiberoptic intubation in an obstetric patient with a vallecular cyst [9]. It does not increase the risk of aspiration in the mother or leads to sedation in the newborn [10]. Our patient was too anxious to undergo awake fiberoptic intubation. We didnot want to administer sedatives in our patient for fear of airway obstruction, as she was able to maintain the airway under inhalational anesthesia, and use of fiberoptic laryngoscope was an alternate method that could have been used after inhalational induction. This was our plan B if the use of tongue depressor had failed. Other methods to negotiate the endotracheal tube that has been used include shifting the cyst to one side with the help of a styletted endotracheal tube [11]or lifting of the cyst with a larger Macintosh or a rigid bronchoscopy blade. An angled atraumatic instrument like Mac gills forceps could also be used to shift the cyst away from the intubation path. Although in this case the cyst was thick walled and there was less likelihood of rupture, in case of thin cysts, two wide bore suctions ought to be ready. Shifting the patient to lateral position might help to reopen the complete airway collapse at induction, especially in children [12]. The use of backward, upward, rightward pressure maneuver has been described in a 4-month-old infant [13]. Consent should also be taken for standby tracheostomy. Marsupialization of the vallecular cyst under local anesthesia has also been reported by Pagellaet al. [14]. In our case, we used a tongue depressor to push the cyst so that a view of laryngeal inlet could be obtained. By doing so, we were able to intubate the trachea with a size 6 polyvinyl chloridere in forced tracheal tube over a gum elastic bougie. There was some resistance while inserting the tube probably because no muscle relaxant had been used. The use of 4% lignocaine spray might have eased intubation in this patient. The use of tongue depressor in the management of vallecular cyst has not been reported in literature. This simple method was helpful in our case mainly because the cyst was firm and could be displaced laterally. If the cyst had been soft or pedunculated, this might not have been possible. If general anesthesiais chosen as induction technique, inhalational induction with careful laryngoscopic examination should precede attempt at intubation. As the use of muscle relaxants may cause complete airway obstruction, they should be administeredafter successful endotracheal intubation. Surgical help to perform tracheostomy or puncture of the cyst should be readily available for which consent should be taken before hand. Conclusion We recommend this simple method of using a tongue depressor as a tracheal intubation aid in anesthetic management of a patient with vallecular cyst. Other atraumatic intubation aids and external laryngeal maneuver might be helpful as well and a gum elastic bougie must be handy in such Monem A et al www.jaccr.com Journal of Anaesthesia and Critical Care Case Reports Volume 4 Issue 1 Jan-Apr 2018 Page 16-18 17 | | | | | F i g u r e 1 : P r e o p e r a t i v e c o m p u t e d tomographyview showing the vallecular cyst. Figure 2: Laryngoscopic view with the cyst obscuring the laryngeal view. Figure 3: After intubation. Figure 4: After excision. Figure 5: Removed cysts.