Airway management for patients with ossification of the anterior longitudinal ligament of the cervical spine

Abstract

Ossification of the anterior longitudinal ligament (OALL), also called Forestier’s disease or diffuse idiopathic skeletal hyperostosis, is characterized by anterior bridging osteophytes of unknown etiology. OALL may cause dysphagia, dyspnea, dysphonia, and acute airway obstruction. We report difficulty in tracheal intubation during anesthesia induction in two OALL patients. In an 82-year-old man, anterior bridging osteophytes (of the cervical region) were observed on preoperative lateral radiograph after several attempts of tracheal intubation for the operation of the anterior fusion of cervical spine. During the same procedure in another 69-year-old man, fiberoptic-assisted awake intubation was extremely difficult because of posterior hypopharyngeal wall protuberance by osteophytes of cervical spine; although tracheal intubation for anesthesia was uneventful on two previous occasions over the months. OALL is usually asymptomatic, but it has been found in 12 % of autopsies and may exaggerate with age. Dysphagia, difficulties with tracheal and/or gastric intubation, acute respiratory compromise, and sleep apnea result from the presence of cervical osteophytes. Anesthesiologists should be aware that tracheal intubation for such patients may be difficult, and thus the preoperative evaluation and airway management need careful consideration.

Ossification of the cervical anterior longitudinal ligament is an underdiagnosed cause of difficult airway: a case report and review of the literature

“…Our literature review revealed that a difficult airway can be found in symptomatic [7,8,10,12,[14][15][16][17][18][19][21][22][23][24][25][26] and asymptomatic [5,6,10,12,14,21] patients with OALL of the cervical spine who require surgery. Therefore, this possibility should be considered by anesthesiologists treating symptomatic patients with OALL and, as presented in this case report, those with cervical disease combined with asymptomatic OALL.…”

“…Of these, 34 full-text articles were evaluated, and 23 papers were potential candidates. One article was excluded because the full text could not be found [7], leaving 22 articles (summarized in Table 1) [5,6,[8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. The excluded articles are presented in the appendix.…”

“…Six patients had no symptoms before intubation [5,6,10,12,14,21], and the rest of the patients had symptoms such as dysphagia, dysphonia, dyspnea, airway obstruction, or restricted motion of the neck [8,9,11,13,[15][16][17][18][19][20][22][23][24][25][26][27]. Awake intubation was chosen for 10 patients [5, 11, 13-15, 20, 22-25], and rapid induction was chosen for 7 patients [6,8,9,16,17,21,23]; fiberscope-assisted intubation was cited as the optimal choice in 13 articles [11, 13-15, 18, 20-27]; other cases favored the direct laryngoscope [5,6,9,16,17,19,23] or the intubating laryngeal mask [13,21]. A small-sized endotracheal tube was selected for 4 patients [6,17,25,27], while a nasotracheal tube was selected for 2 patients [11,22].…”