Airway management in cervical spine ankylosing spondylitis: Between a rock and a hard place

Abstract

We report the perioperative course of a patient with long standing ankylosing spondylitis with severe dysphagia due to large anterior cervical syndesmophytes at the level of the epiglottis. He was scheduled to undergo anterior cervical decompression and the surgical approach possibly precluded an elective pre-operative tracheostomy. We performed a modified awake fibreoptic nasal intubation through a split nasopharyngeal airway while adequate oxygenation was ensured through a modified nasal trumpet inserted in the other nares. We discuss the role of nasal intubations and the use of both the modified nasopharyngeal airways we used to facilitate tracheal intubation. This modified nasal fibreoptic intubation technique could find the application in other patients with cervical spine abnormalities and in other anticipated difficult airways.

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.…”

“…Among the patients included, the most commonly involved cervical vertebrae were C3-C4, followed by C4-C5 and C5-C6, leading to dysphagia and airway obstruction, possibly due to excessive activity. 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].…”

“…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]. The majority of patients required multiple endotracheal intubation attempts, and four patients could not undergo the surgery because of intubation failure [5,14,15,18].…”

Nasal fiberoptic intubation with and without split nasopharyngeal airway: Time to view the larynx & intubate

“…Koerner and Brambrink (2005) [10] reported that while fiberoptic intubation can be achieved with brief apnea, preoxygenation is necessary. Eipe et al (2013) [11] used two nasopharyngeal airways, the first one to ensure delivery of adequate oxygen and the second one was a split nasopharyngeal airway to facilitate fibreoptic intubation.…”