Airway Management in Adult Patients with Deep Neck Infections: A Case Series and Review of the Literature

Abstract

Patients with deep neck infections, especially those with Ludwig's angina, may die as a result of airway management mishaps. Skillful airway management is critical, but a safe method of airway control in these patients is yet to be established. We subjected patients with deep neck infections to fiberoptic tracheal intubation by using topical anesthesia to provide general anesthesia for surgical interventions. Patient characteristics and techniques for intubations were recorded on a special data-collection form. Of the 26 patients, 17 had Ludwig's angina, and 9 had other types of deep neck infections. Three patients were tracheally intubated while in the sitting position, 2 in Fowler's position, and 21 in the supine position with the head up 10 degrees-15 degrees. Tracheal intubations were successful in 25 patients: 19 nasally and 6 orally. After surgery, seven patients were kept tracheally intubated, and five patients had tracheostomies. Complications were limited to three cases of mild epistaxis and four oversedations with transient hypoxemia. Twelve patients remembered part of the procedure, and two considered it unpleasant. Tracheal intubation with a flexible bronchoscope by using topical anesthesia is highly successful in adult patients with deep neck infections. Tracheostomy using local anesthesia is recommended if fiberoptic intubation is not feasible, if the clinician is not skillful in the use of awake fiberoptic intubation, or if intubation attempts have failed.

A Study of Flexible Fiberoptic Bronchoscopy Aided Tracheal Intubation for Patients Undergoing Elective Surgery Under General Anesthesia

“…Devices like various kinds of fiberoptic compatible oral airways have also been made which facilitate the process of FFB aided intubation while keeping the airway patent [13]. Out of all these methods the FFB assisted tracheal intubation is very safe and effective in the trained hands not only electively but also as back up when routine rigid laryngoscopic intubation fails [8,[14][15][16]]. An organised approach and adequate expertise in FFB are the corner stones of success [7].…”

Ludwig’s Angina in Pregnancy Necessitating Pre Mature Delivery

“…Careful evaluation of the airway and prompt antimicrobial therapy with surgical decompression may represent a plausible alternative in pregnant patients [9]. Fibre optic intubation using topical anaesthesia is the first choice for airway control in adult patients with deep neck infections including Ludwig's angina [10]. The objectives for management are avoidance of teratogenic drugs, avoidance of intrauterine foetal hypoxia and acidosis, prevention of spontaneous abortion early in pregnancy, and prevention of premature labour later in pregnancy [11].…”

Obstructing pathology of the upper airway in a post-NAP4 world: time to wake up to its optimal management

“…Both awake transoral or transnasal intubation 9 and tracheal intubation following inhalational induction of general anesthesia 10 have been advocated for less extreme but still difficult situations identified at nasopharyngoscopy. Both techniques have been used successfully in this population, but as NAP4 records, failures have also occurred.…”