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

Abstract

Background: Ossification of the anterior longitudinal ligament (OALL) of the cervical spine is a common, but rarely symptomatic, condition mostly observed in the geriatric population. Although the condition usually requires no intervention, it could lead to a difficult airway and compromise the patient's safety. Case presentation: Here, we describe the case of a 50-year-old man with cervical myelopathy and OALL that resulted in difficult endotracheal intubation after induction of anesthesia. Radiography and magnetic resonance imaging findings showed OALL, with prominent osteophytes involving four cervical vertebrae, a bulge in the posterior pharyngeal wall, and a narrow pharyngeal space. Airtraq® laryngoscope-assisted intubation was accomplished with rapid induction under sevoflurane-inhaled anesthesia. Conclusion: Anesthesiologists should understand that OALL of the cervical spine could cause a difficult airway. However, it is difficult to recognize asymptomatic OALL on the basis of routine airway evaluation guidelines. For susceptible populations, a thorough evaluation of the airway, based on imaging studies and a history of compression symptoms, should be considered whenever possible. In case of unanticipated difficult intubation, anesthesiologists should refer to guidelines for unanticipated difficult airway management and identify OALL of the cervical spine as the cause.

A spray-as-you-go airway topical anesthesia attenuates cardiovascular responses for double-lumen tube tracheal intubation

“…Flexible bronchoscopy is the gold standard for guiding awake tracheal intubation and is an effective method for airway topical anesthesia [ 21 , 29 ]. Also, bronchoscopy is often used to judge and adjust the position of the intubation in DLT tracheal intubation [ 30 ].…”

Pharynx volume derived from three-dimensional computed tomography is associated with difficult intubation in spinal deformity surgery: A retrospective cohort study

“…[ 11 ] Some radiological evaluation also yielded valuable information, such that the hyomental distance <55 mm was associated with difficult laryngoscopy (average value in our study being 33 mm), [ 12 ] Atlanto-occipital gap <6.0 mm (average value in our study being 4.4 mm), [ 13 ] or ossification of the anterior longitudinal ligament resulting in a narrow pharyngeal space. [ 14 ] However the key airway anatomy feature in difficult airway remains inconclusive.…”

Diffuse Idiopathic Skeletal Hyperostosis of Cervical Spine with Dysphagia—Molecular and Clinical Aspects

“…Symptoms related to the locomotive system include neck pain and stiffness. Compression of the throat, esophagus, and trachea can cause dysphagia, shortness of breath, and stridor ( Table 2 ) [ 45 ]. Symptomatic cases are more common in men, and the main complaint is dysphagia (75%).…”

“…The indication for surgical treatment is worsening airway obstruction and/or dysphagia with failed ambulatory therapy [ 61 ]. Surgical intervention is reserved for symptomatic cases that do not respond to nonsurgical treatment, progressive dysphagia with unintentional weight loss, and people with respiratory symptoms [ 45 ].…”