Background: Laryngeal mask airway (LMA) insertion contributes to airway protection in patients with a laryngeal tumor around the glottis. There has been no report of LMA insertion itself exacerbating airway obstruction in such patients. Case presentation: A 62-year-old male underwent elective surgical resection of a large laryngeal polyp. The polyp was attached to the right vocal fold and synchronously swung inward into the trachea and outward to the larynx with inspiration and expiration, respectively. Although manual positive pressure ventilation was easily achieved without any airway obstruction after anesthetic induction, the airway was completely obstructed by the polyp lodged between the vocal cords immediately after LMA insertion. Soon after removal of the LMA, patency of the airway was dramatically improved. Conclusion: Our experience indicates that we should pay attention to airway obstruction due to lodging of the polyp between the vocal cords after LMA insertion in patients with a laryngeal polyp. Keywords: Airway obstruction, Laryngeal polyp, Laryngeal mask airway Background Case presentation Surgery and anesthetic management of patients with a A 62-year-old male weighing 75 kg and with a height of laryngeal tumor occupying the space of the glottis is 162 cm complained of discomfort in the throat. challenging for anesthesiologists because airway obstruc- Preoperative laryngoscopy revealed a large laryngeal tion can occur during surgery. Temporary tracheostomy, polyp attached to the right vocal fold that synchronously endotracheal intubation using a thin endotracheal tube swung inward into the trachea and outward to the (ETT), and high-frequency jet ventilation have been used larynx with inspiration and expiration, respectively for airway management for laryngoscopic surgery with a (Fig. 1a, b). The space between the vocal cords was too rigid laryngoscope in such patients . Another option narrow due to the presence of the polyp for an endo- is a laryngeal mask airway (LMA), which has been used tracheal tube to be inserted. In addition, a surgical for airway protection, and introduction of a flexible procedure could not be performed if the polyp moved laryngoscope for surgery has been successfully used in into the trachea after endotracheal intubation. Thus, we such patients . There has been no report of LMA in- decided to reduce the volume of the polyp by using a sertion itself exacerbating airway obstruction in such pa- flexible bronchoscope through the LMA and then to tients. Here, we report a patient with a laryngeal polyp perform total removal of the polyp by using a rigid la- in whom manual positive pressure ventilation was easily ryngoscope with endotracheal intubation. If the airway achieved after anesthetic induction, but the airway was did not remain patent by such airway management, we completely obstructed by the polyp lodged between the planned to perform temporary tracheostomy for removal vocal cords following LMA insertion. of the polyp using a rigid laryngoscope. The patient was not given premedication, and routine * Correspondence: firstname.lastname@example.org noninvasive monitoring including blood pressure, percu- Satoshi Fuseya and Takashi Ichino contributed equally to this work. taneous oxygen saturation (SpO ), and end-tidal CO 2 2 Department of Anesthesiology and Resuscitology, Shinshu University School was performed in the operating room. SpO was 97% on of Medicine, 3-1-1 Asahi, Matsumoto City, Nagano 390-8621, Japan © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Fuseya et al. JA Clinical Reports (2018) 4:43 Page 2 of 3 Fig. 1 Laryngoscopic images of the glottis in a patient with a large laryngeal polyp. Preoperative laryngoscopic images of the glottis show the large laryngeal polyp attached to the right vocal fold that synchronously swung inward into the trachea and outward to the larynx with inspiration (a) and expiration (b), respectively. An intraoperative image shows that the polyp was located between the vocal cords and immovable after LMA insertion (c). P laryngeal polyp, LMA laryngeal mask airway room air, and oxygen was delivered by a facemask at Discussion 7 L/min in the operating room. During anesthesia that Airway management for laryngoscopic surgery in pa- was induced with incremental administration of propofol tients with a laryngeal tumor includes temporary trache- (total dose of 170 mg), spontaneous ventilation was ostomy, endotracheal intubation using a thin ETT, manually assisted and was followed by manual positive transglottic or intercricoid high-frequency jet ventilation, pressure ventilation without any airway obstruction. and LMA insertion [1, 3]. However, it has been reported However, complete airway obstruction occurred immedi- that the polyp was dislodged by the ETT and airway ob- ately after a size 4 LMA (LMA Supreme™, Teleflex Co., struction occurred when the trachea was intubated . NC, USA) was inserted. Maneuvers including changing When high-frequency jet ventilation is performed, there the LMA position and increasing and decreasing the vol- are risks of complications such as subcutaneous emphy- ume of cuff air did not improve the difficult airway. A sema and pneumothorax . An LMA has been used for flexible laryngoscope revealed airway obstruction due to airway protection, and introduction of a flexible laryngo- the polyp lodged between the vocal cords (Fig. 1c), and scope via the LMA has been successfully used in the polyp could not be moved by pulling with forceps patients with a laryngeal polyp [1, 5]. Thus, we consid- through the LMA. Spontaneous respiration returned, ered that LMA insertion could avoid invasive tracheos- but the airway was still not patent even though the ma- tomy and would allow surgery to be performed using a neuvers were repeatedly tried. SpO decreased to 88%, flexible bronchoscope. and the LMA was removed. Soon after the removal, pa- However, it has been reported that LMA insertion it- tency of the airway was dramatically improved and SpO self can cause deformity of the vocal cords , possibly returned to 100%. Transient tracheostomy was then car- resulting in airway obstruction due to lodging of the ried out under general anesthesia with 2.0% of sevoflur- polyp between the vocal cords as in our case. LMA ane in 40% oxygen with assisted spontaneous ventilation insertion may thus exacerbate airway obstruction in pa- and injection of 250 μg fentanyl. Resection of the polyp tients with a laryngeal polyp in the glottis, and caution was successfully performed using a rigid laryngoscope. should be paid for LMA insertion in such patients. In The tracheostomy was closed on postoperative day 5, our case, the polyp was smoothly swung inward into the and the patient was discharged on postoperative day 7. trachea in inspiration and swung outward to the larynx Fuseya et al. JA Clinical Reports (2018) 4:43 Page 3 of 3 in expiration through the vocal cords during spontan- 3. Jaquet Y, Monnier P, Van Melle G, Ravussin P, Spahn DR, Chollet-Rivier M. Complications of different ventilation strategies in endoscopic laryngeal eous respiration without dyspnea. Accordingly, reduc- surgery: a 10-year review. Anesthesiology. 2006;104:52–9. tion of the volume of the polyp by using a flexible 4. Nakahira J, Sawai T, Matsunami S, Minami T. Worst-case scenario intubation laryngoscope under mask ventilation with light sedation of laryngeal granuloma: a case report. BMC Res Notes. 2014;7:74. 5. Pennant JH, Gajraj NM, Yamanouchi KJ. The laryngeal mask airway and might have been another option. However, this proced- laryngeal polyposis. Anesth Analg. 1994;78:1206–7. ure may also have the risk of unanticipated difficult air- way due to accidental deep sedation, bleeding from the tumor and abrupt body movement caused by surgical intervention. LMA insertion enables successful ventilation in a pa- tient with airway obstruction due to several large laryn- geal polyps . Thus, the use of an LMA contributes to the relief of airway obstruction in some patients with a large laryngeal polyp. However, LMA insertion also has a potential risk of exacerbating airway obstruction in such patients as shown in our case. Thus, when laryngo- scopic surgery with a flexible laryngoscope through an LMA is planned in patients with laryngeal lesions, prep- aration should also be made for transcricoid jet ventila- tion and tracheostomy prior to surgery. Conclusion In conclusion, our experience indicates that we should pay attention to airway obstruction due to lodging of the polyp between the vocal cords after LMA insertion in patients with a laryngeal polyp. Abbreviations ETT: Endotracheal tube; LMA: Laryngeal mask airway; SpO : Percutaneous oxygen saturation Authors’ contributions T Ichino participated in the anesthetic management of the patient. SF and T Ichino drafted the manuscript. ST, KI, and T Ishida gave important feedback on the manuscript. MK revised the manuscript critically. All authors read and approved the final manuscript. Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent was obtained from the patient for publication of this case report. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Received: 10 April 2018 Accepted: 27 May 2018 References 1. Hashmi NK, Mandel JE, Mirza N. Laryngeal mask airway in laryngoscopies: a safer alternative for the difficult airway. ORL J Otorhinolaryngol Relat Spec. 2009;71:342–6. 2. Blais A, Merchant RN, Blackie SP. Transient vocal cord deformity caused by a laryngeal mask airway device during flexible fibreoptic bronchoscopy. Can J Anaesth. 2012;59:724–5.
JA Clinical Reports – Springer Journals
Published: Jun 5, 2018
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