2018 FSA Posters

P025: DOUBLE DIFFICULTY: UNANTICIPATED DIFFICULT DOUBLE LUMEN TUBE PLACEMENT DUE TO AIRWAY ANOMALY
Lucas Bannister, MD, J. Christopher Goldstein, MD; University of Florida

Introduction: According to the ASA, a difficult airway is defined as “the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both” [1]. It is estimated that the incidence of difficult airway in thoracic surgery cases is 3% [2]. Distorted airway anatomy due to prior surgery, radiation, and congenital or acquired airway anomalies may make double lumen endotracheal (ET) tube placement especially challenging. We present a case of Reinke’s edema causing unanticipated difficulty with double lumen ET tube placement.

Case: A 58 year old male with past medical history of nasopharyngeal cancer s/p chemotherapy and radiation, 40 pack-year smoking history, coronary artery disease s/p 3 coronary stents, and moderate COPD presented for a video-assisted thorascopic surgery (VATS) and left upper lobectomy for a left upper lobe pulmonary nodule. A thorough airway exam was obtained and revealed full neck range of motion, greater than three-fingerbreadth mouth opening, no apparent tracheal deviation or scarring, and a Mallampati classification of 2. After intravenous induction of anesthesia and easy mask ventilation, initial laryngoscopy revealed a Cormack-Lehane grade 2b view. However, difficulty with double lumen ET tube placement was encountered due to obstruction of the glottic opening by large, bilateral nodules on the anterior vocal cords. Mask ventilation was resumed, and indirect laryngoscopy with a D-blade was attempted with repeated obstruction of the double lumen ET tube, requiring the placement of a single lumen ET tube and exchange for a smaller double lumen ET tube over an airway exchange catheter. The otolaryngology team was consulted prior to proceeding with surgery to determine if this could represent metastatic disease or if biopsies needed to be obtained to guide diagnosis. Upon evaluation by otolaryngology team with video laryngoscopy, the image was initially believed to be inverted due to the masses’ similarity in appearance to the arytenoid cartilages. The otolaryngology team recommended outpatient follow-up, and the surgery was allowed to proceed. Further work-up in the outpatient setting revealed a diagnosis of Reinke’s edema – benign, “sac-like” polyps of the vocal cords.

Discussion: Found almost exclusively in female smokers, these polyps tend to give patients characteristically deep voices [3]. While dysplasia has been discovered in histologically proven Reinke’s edema, it is believed to be a distinct entity from malignancy [3,4]. Airway obstruction due to Reinke’s edema has been reported in literature, and as in our case, these lesions may present a unique challenge to the anesthesiologist during airway management requiring large diameter airway access such as large single lumen or double lumen ET tubes.