Full text of DOI:10.1007/BF03020497

CARDIOTHORACIC ANESTHESIA, RESPIRATION AND AIRWAY
203
Oral styletted intubation under video control in a
patient with a large mobile glottic tumour and a
difficult airway
[L’intubation orale avec un stylet vidéoguidé chez un patient présentant une
importante tumeur mobile de la glotte et une intubation difficile]
Ichiro Takenaka MD,* Kazuyoshi Aoyama MD,† Motohiro Nakamura MD,* Hiroshi Fukuyama MD,*
Yasunari Urakami MD,* Yukari Takenaka MD,‡ Tatsuo Kadoya MD*
Purpose: With fibreoptic intubation, advancement of the endotra-
cheal tube (ETT) through the glottis is blind. Thus, in patients with
a laryngeal tumour, there is a potential for damage to the tumour.
Previously, we proposed the use of a fibreoptic bronchoscope
Objectif : Pendant l’intubation fibroscopique, la poussée du tube
endotrachéal (TET) au travers de la glotte se fait à l’aveugle. En
présence d’une tumeur laryngée, il y a donc une possibilité d’altérer la
tumeur. Auparavant, nous avons proposé d’utiliser un fibroscope
bronchique (FOB) guidé par une caméra vidéo, ce qui permet de visua-
liser le passage du tube. Cette technique a été utilisée avec succès
chez un patient connu pour problèmes d’intubation et qui présentait
une tumeur glottique.
(FOB)-video camera system to permit visualization of tube passage.
We used this technique successfully in a patient with a known diffi-
cult airway and a large glottic tumour.
Clinical features: A 61-yr-old man with a known history of diffi-
cult laryngoscopic intubation underwent laryngeal microsurgery for
recurrence of a glottic tumour. As preoperative indirect laryn-
goscopy revealed a large, mobile, and pedunculated glottic lesion
obstructing the glottic opening, we planned a conventional awake
fibreoptic intubation. Endoscopy showed that the tumour partially
obstructed the glottis and the space between the tumour and the
glottic opening was very narrow. To avoid damage to the tumour,
we changed to an alternative fibreoptic intubation technique. The
FOB attached to a video camera was passed nasally and a jaw thrust
manoeuver was applied, providing an excellent view of the larynx.
An anesthesiologist inserted the ETT with a curved stylet orally, and
carefully advanced the tube tip into the space between the tumour
and the glottic opening under video control. Absence of damage to
the tumour and passage of the tube between the cords were con-
firmed visually.
Éléments cliniques : Un homme de 61 ans connu pour des pro-
blèmes d’intubation a subi une intervention au larynx en
microchirurgie pour une tumeur récidivante. Comme la laryngoscopie
indirecte préopératoire révélait une importante lésion pédiculée et
mobile obstruant l’ouverture glottique, nous avons planifié une intuba-
tion fibroscopique vigile traditionnelle. L’endoscopie a montré que la
tumeur obstruait partiellement la glotte et que l’espace entre la
tumeur et l’ouverture glottique était très étroite. Nous avons donc
opté pour une intubation fibroscopique modifiée afin de ne pas touch-
er à la tumeur. Le FOB, relié à une caméra vidéo, a été passé par voie
nasale et une manœuvre de projection de la mandibule a été
appliquée pour favoriser une meilleure visualisation du larynx. Un
anesthésiologiste a inséré un TET avec un stylet courbé par voie orale
et, sous contrôle vidéo, a poussé prudemment la pointe du tube dans
l’espace entre la tumeur et l’ouverture glottique. Le système de
caméra vidéo a permis de confirmer l’absence de dommage à la
tumeur et le passage du tube entre les cordes vocales.
Conclusion: This alternative intubation technique, providing a
view of the tube passage into the glottis, was a reasonable method
to avoid potential damage to the glottic tumour by blind tube pas-
sage during conventional fibreoptic intubation.
Conclusion : La technique d’intubation décrite, qui fournit une visua-
lisation du passage du tube dans la glotte, s’est révélée satisfaisante
pour éviter de toucher la tumeur glottique par le passage du tube à
l’aveugle pendant l’intubation fibroscopique traditionnelle.
From the Departments of Anesthesia, Nippon Steel Yawata Memorial Hospital,* the Moji Rosai Hospital,† and the Emergency Life Saving
Technique Academy,‡ Kitakyushu, Japan.
Address correspondence to: Dr. Ichiro Takenaka, Department of Anesthesia, Nippon Steel Yawata Memorial Hospital, 1-1-1
Harunomachi, Yahatahigashi-ku, Kitakyushu 805-8508, Japan. Phone: 81-93-671-9420; Fax: 81-93-671-9605; E-mail:
itaken@d4.dion.ne.jp
Accepted for pulication September 5, 2001.
Revision accepted November 16, 2001.
CAN J ANESTH 2002 / 49: 2 / pp 203–206

204
CANADIAN JOURNAL OF ANESTHESIA
IRWAY management for patients with a
1
, 2
laryngeal tumour requires special attention.
Large glottic tumours obstruct the glottis and
make intubation difficult. When advancing an
A
endotracheal tube (ETT) into the glottis during intuba-
tion, the ETT can impact on the tumour and large
mobile tumours pushed by the ETT may cause airway
obstruction. Advancement of the ETT may slip the bro-
ken tumour into the trachea, leading to foreign body or
tumour implantation. Bleeding from the damaged
tumour may occur. To avoid these problems, careful
advancement of the ETT under direct observation is
essential in these patients. In patients with an anatomi-
cally difficult airway, however, observing tube advance-
ment is difficult. Fibreoptic intubation is a reliable
3
–6
method for a difficult intubation, but advancement of
the ETT through the glottis is blind.5 Previously, we
proposed an alternative intubation technique using a
fibreoptic bronchoscope (FOB)-video camera system to
observe the correct advancement of the ETT in patients
FIGURE Alternative intubation technique using the combina-
tion of a fibreoptic bronchoscope (FOB)-video camera system and
a styletted endotracheal tube (ETT). The FOB attached to the
video camera is passed into the nasopharynx, which provides the
view of the larynx on the video monitor. An operator inserts the
ETT with the stylet curved as a “hockey stick” into the trachea
under video control.
, 6
6
with difficult airways. We describe a case of successful
intubation using this technique in a patient with a docu-
mented history of anatomically difficult laryngoscopic
intubation who had a large, mobile glottic tumour that
partially obstructed the glottic opening.
monitors, including electrocardiography, indirect arte-
rial pressure, pulse oximetry, and capnography, were
applied and the patient received 2.5 mg midazolam iv.
Topical anesthesia of the oropharynx was achieved
using commercially available 8% lidocaine spray. A
superior laryngeal nerve block was performed with 2
mL of 1% lidocaine and the block was repeated on the
opposite side. An Ovassapian intubating airway was
then inserted into the mouth. The anesthesiologist
inserted a 4.9 mm FOB (BF-P30, Olympus, Tokyo,
Japan), passed into a 6.0-mm internal diameter micro-
laryngeal tube (Mallinckrodt, Athlone, Ireland),
through the intubating airway into the oropharynx.
Supplemental oxygen was insufflated via the working
channel. Endoscopy showed that a large glottic
tumour partially obstructed the glottis. Because the
space between the tumour and the glottic opening was
very narrow, we considered that the ETT advancing
over the FOB could push the tumour into the glottis
or damage it. So, we changed from a conventional
fibreoptic technique to an alternative technique
Case report
A 61-yr-old man (87 kg, 169 cm) with recurrence of
a glottic tumour was scheduled for laryngeal micro-
surgery. Two years previously, the patient had under-
gone microlaryngoscopy for diagnosis of a small
glottic lesion under general anesthesia. The anesthetic
record revealed that the patient’s trachea had been
intubated using a FOB because, using the Macintosh
laryngoscope, the anesthesiologist had been unable to
lift the epiglottis from the posterior pharyngeal wall
sufficiently and the view of the glottis had been Grade
3
according to Cormack and Lehane’s classification.
Histology demonstrated a squamous cell carcinoma of
the glottis, and the patient was treated with irradia-
tion. At the preoperative visit, an experienced anes-
thesiologist assessed the patient’s airway as Mallampati
Class 3 with a thyromental distance of 6 cm, one third
reduction of atlanto-occipital joint extension, and a
mouth opening of 5 cm. On physical examination, the
patient had mild inspiratory stridor. Indirect laryn-
goscopy revealed a large, mobile and pedunculated
glottic lesion obstructing the glottic opening. We
planned a conventional awake fibreoptic intubation.
After counseling the patient regarding the need for
awake intubation, he agreed to the procedure.
6
described previously (Figure). After the intubating
airway was removed and the nostril was anesthetized
with long cotton-tipped applicators soaked in 4% lido-
caine, a nasopharyngeal airway was inserted. An assis-
tant passed the FOB attached to a video camera
(OTV-S5 Olympus) through the nasopharyngeal air-
way and performed a jaw thrust manoeuver. This pro-
The patient was premedicated with 0.5 mg atropine
im. In the operating room, standard noninvasive

Takenaka et al.: GLOTTIC TUMOUR AND FOB INTUBATION
205
vided an excellent view of the larynx which was dis-
played on the monitor screen. The anesthesiologist
inserted a 6.0-mm internal diameter cuffed reinforced
tube with a stylet in the “hockey stick” configuration
into the oropharynx, and carefully advanced the ETT
tip into the space between the tumour and the glottic
opening under video control. Absence of damage to
the tumour and passage of the ETT between the cords
were confirmed visually. Successful intubation was
confirmed further by capnography and anesthesia
induced with propofol iv. Oxygen saturation did not
decrease below 94% throughout intubation. The glot-
tic tumour was removed surgically and the trachea was
extubated uneventfully. Pathology confirmed recur-
rence of the glottic carcinoma. Two weeks later, the
patient underwent a total laryngectomy.
as an intubating introducer may be useful in this situ-
ation. Finally, view of the glottis via the FOB is not
6
obstructed by manipulation of the ETT into the tra-
chea because our technique allows the FOB and the
ETT to be controlled independently. The excellent
view obtained helps advance the ETT while avoiding
impact on the tumour. A disadvantage of the tech-
nique is the necessity to use the nasal route.
In our patient, application of the jaw thrust
manoeuver provided a clear fibreoptic view of the
glottis and sufficient room to control the ETT by lift-
ing the tongue, the epiglottis and laryngeal soft tis-
9
sues. We did not use a laryngoscope for these
purposes because, in some patients with a difficult air-
way, the laryngoscope cannot lift the epiglottis from
the posterior pharyngeal wall sufficiently, expand
structures around the glottis, and provide a good
1
0
Discussion
fibreoptic view of the glottis. Topical anesthesia of
the airway and conscious sedation with midazolam
allowed the successful execution of awake intubation.
Adequate topical airway anesthesia suppressed gag and
cough reflexes, and was essential to obtain an excellent
fibreoptic view and to advance the ETT safely.
Sedation should be titrated carefully to avoid exacer-
bation of airway obstruction caused by loss of muscle
tone in patients with large laryngeal tumours.
7
Most laryngeal tumours occur in the glottic region
and are likely to be pushed, damaged or to bleed dur-
ing passage of an ETT during intubation. To avoid
these problems, careful advancement of the ETT
under observation throughout intubation attempts is
essential.
Conventional laryngoscopy enables to see the
advancement of the ETT under direct vision when a
full view of the glottis is obtained. In some patients,
direct laryngoscopy cannot provide a full view. Many
intubation techniques have been devised for such
patients,3 but few allow a view of the ETT advance-
ment throughout intubation. Even with conventional
fibreoptic intubation, advancement of the ETT over
In summary, this case of known, anatomically diffi-
cult intubation had the potential for complications
during blind passage of the ETT during conventional
fibreoptic intubation. An alternative intubation tech-
nique, combining the FOB-video camera system and a
styletted ETT, permitted an excellent view of the ETT
passage into the glottis. We believe this is a reasonable
method to prevent problems associated with a large
laryngeal tumour in patients with a difficult airway.
, 4
5
,6
the FOB is blind
and may impact on a large
tumour.5 Alternative laryngoscopes, such as the
Bullard laryngoscope, the Wuscope, and the
Upsherscope, allow visualization of ETT advance-
8
ment. With these laryngoscopes, the viewing end of
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