Journal of Anaesthesiology Clinical Pharmacology

: 2013  |  Volume : 29  |  Issue : 2  |  Page : 283--284

Video laryngoscopy added fiberoptic intubation in a patient with difficult airway

Nidhi Gupta, Mihir Prakash Pandia, Hemanshu Prabhakar, Madhur Chauhan 
 Department of Neuroanaesthesia, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Mihir Prakash Pandia
Department of Neuroanaesthesia, All India Institute of Medical Sciences, New Delhi - 110 029

How to cite this article:
Gupta N, Pandia MP, Prabhakar H, Chauhan M. Video laryngoscopy added fiberoptic intubation in a patient with difficult airway.J Anaesthesiol Clin Pharmacol 2013;29:283-284

How to cite this URL:
Gupta N, Pandia MP, Prabhakar H, Chauhan M. Video laryngoscopy added fiberoptic intubation in a patient with difficult airway. J Anaesthesiol Clin Pharmacol [serial online] 2013 [cited 2021 Apr 18 ];29:283-284
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Full Text

Dear Editor,

Airway management of patients with fixed upper cervical spine is a great challenge to the anesthesiologist and when the cervical mobility is restricted due to disease or prior surgery, intubation using direct laryngoscopy is often difficult and at times impossible because of limited view of glottic opening. [1],[2] We present a case of a difficult airway due to prior fixation of cervical spine in a tracheostomized child where videolaryngoscopy was of great help for facilitating fiberoptic intubation under general anesthesia (GA).

A 12 year old male child, weighing 40 kg, with diagnosis of operated case of atlanto-axial dislocation, wedge compression fracture of 5 th cervical vertebrae and spinal cord compression was scheduled for reexploration, C5 corpectomy, fibular bone grafting and anterior cervical plating. Six months prior a C1-C2 posterior fixation and C3-C6 lateral mass screw and rod fixation was done. On preoperative examination, patient was tracheostomised with a size 6 cuffed Portex tracheostomy tube (TT) in situ and was on full support mechanical ventilation. On auscultation of chest, there were bilaterally equal breath sounds with crepitations. Though the patient maintained 100% SpO 2 during positive pressure ventilation, sudden fall in saturation was noticed while discontinuation of ventilation during endotracheal suctioning. Cervical spine magnetic resonance imaging prior to the second surgery revealed kyphosis of cervical spine with posterior bulge of C5 vertebral body compressing the cervical spinal cord and atrophy of cervical spinal cord at C2 and C5 level [Figure 1]. Since the planned surgical site was in close proximity of the tracheostomy wound, it was decided to replace the TT with an orotracheal tube (OTT). In view of a restricted mouth opening (2.5 cm) and Mallampati class III airway, fibreoptic intubation under GA was planned. After administering fentanyl (80 mcg), propofol (40 mg) and rocuronium (40 mg), multiple attempts of fiberoptic intubation were made, but the glottic opening could not be visualized. Even maneuvers like, pulling out of tongue and jaw lift did not help in improving the view. Meanwhile patient received mechanical ventilation through the tracheostomy tube. C-MAC video laryngoscope was then used to secure the airway. On videolaryngoscopy, bilaterally enlarged tonsils, aryepiglottic folds and only tip of globular swollen epiglottis was visualized after extreme backward-upward-rightward pressure [Figure 2]. Attempts to pass a gum elastic bougie beneath the epiglottis were unsuccessful. A decision was then made to maneuver fiberscope tip under direct vision, through C-MAC video laryngoscopic view obtained on screen [Figure 3]. After few attempts, the tip of the fiberscope was successfully passed beneath the epiglottis. On further advancement of fiberscope, carina was visualized and a size 6.0 mm OTT was threaded until it encountered resistance by TT. The TT was then removed and the OTT advanced past the tracheostome. Intraoperative course remained uneventful and the patient was shifted to intensive care unit with OTT in situ and tracheostomized later, after surgical site healing.{Figure 1}{Figure 2}{Figure 3}

Fixation of the cervical spine makes subsequent airway management more difficult. [1],[2] Recently, in a radiographic analysis in normal patients, Masato and colleagues have shown that the occipito-upper-cervical alignment (O-C2 angle) has a great impact on the oropharyngeal space. [3] The reduction of the O-C2 angle following posterior fixation moves the maxilla in a flexed position and shifts the mandible posteriorly, resulting in an airway stenosis at this level. The posteriorly fixed spine and associated kyphotic deformity might have decreased the available oropharyngeal space in our patient.

In our patient, intubation with video laryngoscope became extremely difficult as a result of combination of posteriorly fixed spine with kyphotic deformity; swelling of the tongue, oropharyngeal structures, epiglottis and aryepiglottic folds secondary to chronic presence of nasogastric tube and trauma due to repeated suctioning. Fiberoptic intubation was not possible because the swelling of the oropharyngeal structures and the narrowed oropharyngeal space prevented us from properly maneuvering the fiberscope and visualizing the glottic opening. C-MAC video laryngoscope helped by pushing the swollen tongue aside, making more room available for maneuvering the fiberscope within the oral cavity and also in guiding the tip of fiberscope beneath the epiglottis into the glottic opening by aiding the visualization of the fiberscope tip in relation to other oropharyngeal structures.

This case report highlights the difficulty that may be encountered while securing the airway in patients with cervical spine instrumentation and the utility of video laryngoscopy as an aid to do fiberoptic intubation in a difficult situation.


1Schoenhage K, Koenig HM. Unanticipated Difficult Endotracheal Intubations in Patients with Cervical Spine Instrumentation. Anesth Analg 2006;102:960-3.
2Manninen PH, Jose GB, Lukitto K, Venkatraghavan L, El Beheiry H. Management of the airway in patients undergoing cervical spine surgery. J Neurosurg Anesthesiol 2007;19:190-4.
3Ota M, Neo M, Aoyama T, Ishizaki T, Fujibayashi S, Takemoto M, et al. Impact of the O-C2 angle on the oropharyngeal space in normal patients. Spine (Phila Pa 1976) 2011;36:E720-6.