case reports A case report: the questionable airway LT THOMAS R. RATIGAN, CRNA U.S. Navy Nurse Corps Bethesda, Maryland The author discusses a case involving a four-year-old female who underwent surgery for the removal of a large tumorous growth involving her upper airway. The report emphasizes the need for adequate and thorough evaluation of a patient's airway prior to induction of anesthesia. This case report is directed primarily at the preoperative and intraoperative anesthetic airway management of a fouryear-old, Caucasian female admitted to our hospital's otolaryngology department with a diagnosis of bilateral congenital cystic hygroma hemolymphangioma. Figure 1 is a photograph of our patient as she was presented to us on the day prior to surgery. The admitting physical examination proved unremarkable with the exception of her cystic hygroma. Past medical history of note included: (1) resection of cystic hygroma of the chin and neck at birth with gastrostomy; (2) tracheostomy at age three weeks; (3) resection of recurrent left neck hygroma at age four weeks; (4) resection of recurrent right neck hygroma at age one year; and (5) partial left glossectomy for hygroma of the tongue, also, suturing of tracheostomy opening at age one year. Figures 2, 3 and 4 are photographs arranged in chronological order. Figure 2 depicts the patient at one year of age, Figure 3 at two years, and Figure 4 at approximately four years. The sequence of photographs allows one to observe the regrowth of the cystic hygroma in relation to the age of the patient, despite multiple surgical procedures. At the time of the patient's admission, the proposed surgical procedure was listed as bilateral mandibular osteotomies, partial glossectomy, bilateral submandibular resection of lymphangioma and tracheostomy. Preoperative considerations Preoperatively, we were faced with three major considerations. Our first was that of a possible "difficult airway." Our concern was based on several factors including: (1) an enlarged mandible; (2) enlargement of the tongue secondary to tumor; (3) large tumor growth in the submandibular region and finally; (4) the possibility of airway abnormalities in the glottic and subglottic regions, in light of the patient's previous tracheostomy. Preoperative assessment of the first problem was approached basically in four steps. The first involved obtaining February/1979 67
Figure 1 Figure 3 Figure 2 Figure 4 a complete history from the parents with regard to the child's previous airway difficulties, including dyspnea, cyanosis, retraction, stridor and other signs of respiratory embarrassment. This history of respiratory difficulty since her last surgical procedure proved to be unremarkable. We subsequently consulted with the patient's primary surgeons to obtain their opinion of her airway, based on indirect laryngoscopy. Following this consultation, various members of the anesthesia department who were to be concerned with the patient's anesthetic management examined her upper airway. Finally, lateral neck roentgenographic films were obtained. As seen in Figures 5 and 6, the lateral neck films exhibit a grossly enlarged mandible with a totally normal air column. The second major consideration in Journal of the American Association of Nurse Anesthetists
Figure 5 Fgr Figure 7 Figure 6 Figure 8 February/1979
the anesthetic management of this child was the measurement and replacement of the anticipated large volume blood loss as well as what monitoring would be required. A third consideration was that of heat loss during a potentially prolonged operative period. Although all three of these considerations were of concern, this case report focuses primarily on the individual with a highly questionable airway Following her preoperative evaluation, our patient was placed NPO after midnight the evening prior to surgery. At 6 a.m. on the day of surgery, she was given 0.3 mg of atropine intramuscularly, with narcotics intentionally omitted. The patient arrived in the operative suite awake and alert with no apparent respiratory distress, even in the supine position. The patient was then transported to the operating room and positioned on the operating room table. An intramuscular injection of ketamine hydrochloride, 50 mg, was then administered to facilitate the placement of several intravenous routes and a left radial arterial line. The patient was given oxygen, FIO2 of 1.0, through a Bain circuit. Airway observation was constant with no respiratory difficulty noted. Halothane was then administered slowly in increasing concentration through a fluotec vaporizer. The patient was initially allowed to breathe spontaneously. An interesting point to note is that this four-year-old child required the use of a small adult mask and the placement of a no. 4 Guedel adult oral airway in order to assure adequate ventilation. With the oral airway in place, assisted ventilation was easily accomplished and respiratory difficulty was not observed. At this point, it was felt safe to add nitrous oxide in a 50% concentration to facilitate a more rapid deepening of anesthesia. When the patient was appropriately anesthetized, laryngoscopy was performed with a Miller two blade, without the aid of muscle relaxants. Upon laryngoscopy, the vocal cords were easily visualized and the child was then intubated atraumatically with a 5.0mm endotracheal tube, without cuff, via the oral route. Tracheostomy was subsequently performed and a 4.5mm Annode tube, with cuff, was inserted into the tracheostomy opening. In Figures 7 and 8, one is able to visualize several interesting details. In the more lateral view of the patient's head, for example, the grossly enlarged mandible can be easily observed. This is again clearly visualized in the anterior-posterior view of the patient's face. Conclusion The anesthetic course for this patient was unremarkable. The patient was subsequently discharged from the hospital and recovered satisfactorily at home. Though this operation fortunately proved to be rather uneventful from the "airway" point of view, the nurse anesthetist is reminded of the critical importance of following a systematic preoperative evaluation of the individual's airway whenever any question exists as to potential difficulties. AUTHOR'S NOTE: The author wishes to state that the opinions in this article are his own and are not to be construed as officer views of the Department of Anesthesiology, National Naval Medical Center, Bethesda, Maryland, the Navy Nurse Corps, the Department of the Navy or the Department of Defense. ACKNOWLEDGMENT The author would like to express his appreciation to CDR Brian McAlary, chairman, Department of Anesthesiology, National Naval Medical Center, Bethesda, Maryland; to the staff of the Medical Photography Department, National Naval Medical Center, Bethesda, Maryland and to Mrs. Mary Pfeifer for her clerical assistance. 70 Journal of the American Association of Nurse Anesthetists
AUTHOR Thomas Ratigan, CRNA, is a graduate of the Ellis Hospital School of Nursing, Schenectady, N.Y. He currently holds the rank of lieutenant, Nurse Corps, US Navy. LT Ratigan received his anesthesia training through the US Navy and The George Washington University, Washington, D.C. LT Ratigan is currently a staff nurse anesthetist in the anesthesiology department, National Naval Medical Center, Bethesda, Maryland. February/1979