Unexpected difficult airway management in a transgender female patient

Abstract

A transgender female patient, who had previously undergone gender-confirming feminisation surgery to the face and larynx, was scheduled for thoracic surgery requiring one-lung ventilation. We encountered unexpected difficult airway management and difficulty inserting an appropriately-sized double-lumen tube. A size 41Fr double-lumen tube, which is selected commonly for biological males, was used eventually for lung isolation and subsequently exchanged for a size 6.5 single-lumen tracheal tube at the end of the case, before successful extubation with a staged extubation set. It is important to highlight the challenges faced, as the care of transgender patients is likely to be unfamiliar to most anaesthetists, despite the increase in the number of gender-confirming procedures performed. Many of these procedures involve the face and airway and can result in significant challenges for airway management, including appropriate sizing of tracheal tubes and their correct placement. It is also possible that patients may not volunteer a history of these procedures and it should be enquired about specifically as part of the anaesthetic pre-assessment.

Perioperative Care of Transgender and Gender-Diverse Patients: A Biopsychosocial Approach

“…Some experts recommend using a smaller endotracheal tube in anticipation of potential subglottic stenosis, as unexpected difficult airway scenarios have been reported in patients with prior feminization laryngoplasty. 69 Additionally, FFS often involves surgery on the jaw to feminize the lower face, 70 which may result in reduced mandibular height, width, and mobility, rendering future mask ventilation potentially challenging. Due to difficult airway scenarios that may occur during subsequent surgeries, feminization laryngoplasties and FFS are typically performed as the final GAS.…”

“…68 Certain surgical approaches can also result in a shorter and thinner vocal fold, smaller glottic opening, altered cricothyroid distance due to scar tissue, and shorter thyromental distance with reduced mandibular space, which may make endotracheal intubation and emergent surgical airway challenging. 69 Chondrolaryngoplasty may result in scar formation near the cricothyroid membrane. Some experts recommend using a smaller endotracheal tube in anticipation of potential subglottic stenosis, as unexpected difficult airway scenarios have been reported in patients with prior feminization laryngoplasty.…”

Sex and gender in respiratory physiology

“…Transgender/transsexual patients: new challenges for clinical treatment The number of transgender people is increasing together with the number of gender re-assignment procedures being performed. Just to provide some numbers, ∼200 000-500 000 transgender people currently live in the UK, while 3256 transsexual patients underwent surgical procedures in 2016 as reported by the American Society of Plastic Surgery [139,140]. Unfortunately, the literature on transgender/transsexual subjects is scant or absent.…”

“…For example, breast surgery (either augmentation or reduction) does not change the shape of the lungs, being more pyramidal in male [145], and of the ribcage, with men's ribs being more horizontally oriented [146]. By contrast, procedures involving the shape of the face, of the jaw and of the airways might have important implications for mask ventilation and tracheal intubation [139]. Finally, HAYNES and STUMBO [9] showed how the use of non-birth sex influences the interpretation of spirometry data, therefore placing these patients at risk for misdiagnosis (either over diagnosis or under diagnosis of lung disease) and, consequently, inappropriate treatment.…”

Novel presentations, rare complications and educational content: cases in clinical practice

“…They propose the use of the SPADE framework (surgical stage; patient requirements; anticipated risks; decision to be made; and elected plans A and B) to detail the considerations for each stage of a complex procedure, and devise a safe and effective airway management plan for the peri-operative course. In a thought-provoking report, Vowles et al describe airway management considerations, with a focus on one-lung ventilation, for a transgender female patient [19]. This is a topic currently not included on training curricula in the UK, and the authors argue for more awareness of the relevant issues associated with anaesthetising patients who have undergone gender-confirming surgery.…”