nicole weiss, md august 24, 2011. height: weight: airway exam: malampatti: iii thyromental...
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Morbidity & Mortatlity
Nicole Weiss, MDAugust 24, 2011
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64 y/o male with a h/o of a-fib, presenting for a hybrid mini-maze
Height:Weight:Airway Exam:
Malampatti: III Thyromental distance: II Mouth opening: II Thick Neck, Full Extension
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***The Airway***On the up side, we could ventilateAttempt #1: Direct Laryngoscopy
Grade III/IV view; in light of DLT, handed over to staffAttempt #2: Direct Laryngoscopy
37 Fr DLT placed in esophagusAttempt #3: Glidescope
Grade I view Unable to pass DLT secondary to small mouth opening, difficult angle Attempted to use eschmann with glidescope, but too flimsy to make
curve Placed a single lumen ETT
Attempt #4: Cook Catheter Placed but unable to slide DLT over Single lumen ETT placed again
Attempt #5: Smaller Cook Catheter Still unable to pass DLT Single lumen ETT placed again
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Case AbortedDecision made to cancel the case
Considered bronchial blocker, univent tube Safest option to simply stop
Plan: Extubate in a controlled setting & reschedule
the casePt taken to PACU intubatedPt admitted overnight for observation and discharged home the following morning
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Unfortunately…this was not the end of the story
Patient continued to have persistent neck painReassuredTwo days later, still complaining of neck pain with an “expanding mass”, difficulty swallowingPresented to VA Urgent CareCT done…
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Parapharyngeal, paratonsillar abscess (5.5x2.6cm)
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Still not the end:Admitted to the ICUPlaced on IV antibioticsENT took back to the OR for a neck exploration
Found 2cm laceration of the right pillar tract that communicated and had fistulized to the right neck
Right submandibular, parapharyngeal abscessI&D grew out StrepIV antibiotics continued in houseFeeding tube placed for patient to be NPO for one week
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Flint: Cummings Otolaryngology: Head and Neck Surgery, 5th edition
The morbidity of intubation
Intubation far most common cause of laryngeal trauma10% of patients have demonstrable laryngeal pathology one day after short term intubation for surgeryLonger term intubation results in laryngotracheal injuries in 90% of patients with long term sequelae in 11%
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Was there a better option?
Glidescope or fiberoptic earlier?
Univent tube?Good for challenging airwaysDo not need to be exchanged after the case
Single lumen tube placed first with a cook catheter exchangeMay have been successful if done prior to anyway airway trauma