Laryngeal ball valve tumor GVL and Shikani*

Presented by Dr. James DuCanto, Aurora St. Luke's Medical Center.

The presented video illustrates a careful, stepwise approach to the airway management of a patient with the partially obstructed airway.

A specialized, four channel digital video recorder (DVR) was used to handle the video feeds from the various endoscopes utilized during the patient's care. The DVR simplified the display of video endoscopy information, as well as the recording of the procedure with prior patient consent. Post procedure editing allowed endoscopy views to be imbedded in the side-camera image.

Case presentation:

A 79 y.o. male with mobile, fungating T2N0 squamous cell carcinoma of the left vocal cord involving perilaryngeal tissues, presented with progressive shortness of breath and diminished exercise tolerance. The patient had minimal inspiratory stridor, as he was able to self-regulate the rate and depth of breathing to reduce the degree of dynamic airway obstruction. There was no tracheal extension of the tumor, and the patient’s past medical history was otherwise non-significant.

On presentation the patient was a vibrant and pleasant elderly male, who cooperated with the preoperative interview and physical exam. Examination of the patient’s airway revealed a Mallampati class 2 airway, thyromental distance of 7.5 cm, and a head-and-neck range of motion of approximately 90 degrees. Neck was without visible distortion, no perceptible masses were palpated on physical examination, and the cricothyroid membrane was easily identifiable.

Preoperative discussion regarding airway management and surgical plan with the surgeon addressed the potential for an awake tracheostomy, and possible laryngectomy, should the tumor be found to deeply invade the larynx and laryngeal cartilages. Alternatively, should the tumor be removed superficially, laryngectomy could be avoided. The airway management plan was formulated to allow for avoidance of awake tracheostomy, and further in-depth surgical evaluation and resection of tumor with the patient anesthetized.  

Intraoperative Care:

The patient was brought to the operating room and connected to the monitoring array (ECG, SpO₂, NIBP), and provided with supplemental O₂ by nasal cannula at 2 liters per minute. With the patient awake, topical anesthesia of the patient’s upper airway was achieved with 3 ml of 4% lidocaine gargle and swallow, and 6 ml of topical lidocaine applied to the epiglottis and mass. 

A flexible fiberoptic examination of the hypopharynx and larynx with a Pentax FB-18P (6 mm O.D.) bronchoscope through an Ovassapian intubating airway revealed that the tumor was attached to the left vocal cord, and pivoted anteriorly, superiorly and leftward with spontaneous ventilation (towards the 10 o'clock direction, referencing the face of a clock). It was determined from this examination that the larynx and trachea could be successfully exposed and navigated from an endoscopic approach from an inferior-right approach to the larynx and tumor (towards the 5 o'clock direction).  The plan was to achieve this endoscopy and intubation with the use of moderate sedation, and utilize surgical airway management in the event of the procedure failure.

Due to the size, motion and lack of view of the larynx on flexible fiberoptic endoscopy, an approach to the intubation procedure was selected that utilized two video enabled endoscopes: the Glidescope video laryngoscope and the Shikani Optical Stylet. With moderate sedation utilizing the IV infusions of Remifentanil 0.05 mcg/kg/min and Propofol 50 mcg/kg/min, some difficulty inserting the Glidescope into the patient's mouth was encountered, likely due to oversedation. The Glidescope was utilized to expose the epiglottis and tumor, and the Shikani Optical Stylet was introduced at the 5 o'clock position to the tumor, navigating the mass with the tip of the Mallinkrodt 6.0 ETT leading the optical stylet. Upon passing the mass, the interior of the laryngeal cartilage was visualized with the Shikani Optical Stylet video channel, and the tracheal tube was easily advanced off the stylet without resistance.

Intraoperative video collected during the surgical procedure revealed that the mass was easily removed from the patient's left vocal cord, leaving a raw appearing (but non bleeding) surface through the surgical laryngoscope. A dilute solution of epinephrine was applied to the raw surface of the left vocal cord by the surgeon immediately prior to removal of the surgical laryngoscope.

A plan was formulated to allow for smooth emergence and extubation in the operating room, with the understanding that a surgical airway may still be required in the event of the failure of the patient to maintain a patent airway following emergence. The patient's airway was thoroughly suctioned with a Yankauer suction, and a Bailey maneuver was performed with an Air-Q size 4.5 prior to emergence (the insertion of a supraglottic airway posterior to an indwelling tracheal tube), and the patient was allowed to emerge from the Remifentanil-Sevoflurane anesthetic. With return of adequate spontaneous ventilation, the tracheal tube was removed without incident, as the patient continued to ventilate without assistance through the Air-Q supraglottic airway. 

Upon full emergence from anesthesia, the patient’s airway was suctioned again and the Air-Q supraglottic airway was removed. The patient regained consciousness and awareness to such an extent that he was able to move himself over to the transport cart with minimal assistance.

Postoperatively, the patient had undergone chemo- and radiation therapy, with excellent results. At 4 year follow-up, he continues to thrive and be disease-free, with some long-standing benign mild erythema of the left vocal cord.

Suggested Discussion Topics:

1. What is the rational approach to the partially obstructed upper airway?
2. What is the advantage of a combined video intubation technique used in this patient?
3. Would you do an awake or asleep intubation in this patient?
4. What other extubation strategies could be utilized in this patient?

For further discussion of management of the obstructed airway, please see the Featured Article on the use of transtracheal jet ventilation (TTJV) in critical airway obstruction.