Emergency videoendoscopic endonasal tracheal intubation for severe upper airway stenosis

Abstract

Purpose Upper airway stenosis is one of the most formidable situations in medicine and is frequently encountered in the ENT clinic. We introduce here our method of emergency endonasal endotracheal intubation under videoendoscopic observation. Methods Transnasal endoscopic observation was done, and the region of airway stenosis was detected. Then, the endotracheal tube was prepared and the endoscope was inserted into the tube. The endoscope with tube was inserted up to the larynx. Immediately after the administration of lidocaine to the larynx, the endoscope with tube was inserted to the endolarynx and then to the trachea. The endotracheal tube was tightly held in the nostril, and the endoscope was removed. Results We have encountered four cases this year. The primary disease developing airway stenosis was acute epiglottitis due to pharyngeal and deep neck abscesses in three cases and laryngeal edema due to Ludwig's angina. All patients underwent uneventful intubation, and dyspnea was immediately ceased. Conclusion In cases showing severe suffocation, the clinician should perform airway maintenance even in an outpatient setting apart from a more monitored setting like the operation room. This technique resembles the usual nasal endoscopic laryngeal observation and is done even in the usual ENT office and/or emergency room. The supine position tends to worsen airway stenosis in patients with upper airway stenosis; however, this technique can be performed in a sitting or semi-sitting position. This method is less invasive for patients and also reduces the risk to the medical staff, especially in this COVID-19 era.

Trends in Preoperative Airway Assessment

“…A preoperative flexible nasoendoscopy with tongue protrusion has also been shown to improve the prediction of the modified Cormack–Lehane grade during a conventional laryngoscopy [ 31 ]. A prospective feasibility study and a case series report showed that a fiberoptic nasal endoscope armed with an intubating tube could be used for the awake nasotracheal intubation of a cohort with upper airway pathology, revealing the possibility of using this device for both airway evaluation and management in elective cases or emergencies [ 35 , 36 ].…”

"Tracheal Stenosis as a Consequence of Orotracheal Intubations and Mechanical Ventilation in Time of Pandemic"

“…Three cases accompanied by a deep throat and pharyngeal abscess required surgical drainage. These cases underwent tracheostomy, so the tube was extubated [12].…”

An Awake Flexible Scope Intubation for a Patient With Trisomy 21, COVID-19, and Ludwig’s Angina

“…Additionally, flexible scope intubation allows maintenance of spontaneous negative-pressure ventilation for a patient in whom airway collapse or obstruction may occur with muscle paralysis and positive-pressure ventilation, as may be the case for a patient with Ludwig's angina. Furthermore, flexible scope intubation is now seen as the preferred first-line approach to securing the airway for these patients, supplanting the previous gold standard technique, a surgical airway [1][2][3][4][5].…”