Unanticipated difficult endotracheal intubation due to an undiagnosed pharyngeal web

Corresponding author: Jong In Oh, M.D., Department of Anesthesiology and Pain Medicine, National Police Hospital, Garakbon-dong, Songpagu, Seoul 138-708, Korea. Tel: 82-2-3400-1323, Fax: 82-2-3400-1270, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC An unexpected difficult airway during the induction of general anesthesia may be challenging for anesthesiologists. We present the case of an unsuspected difficult intubation caused by an undiagnosed pharyngeal web and tracheal stenosis. An 85-year-old, 40 kg, 150 cm woman was scheduled for a combined operation of cataract and urinary incontinence. In her medical history, she had dementia and Parkinson’s disease that were both treated with medication, and her preoperative ECG and chest X-ray showed a complete right bundle branch block and atelectasis in the left lower lobe. In the preanesthetic visit, she was classified as Mallampati I, showing no particular abnormality. General anesthesia was induced with fentanyl 50 μg, thiopental sodium 200 mg and rocuronium 40 mg. Under direct laryngoscopy (Macintosh curved blade #3), an oval structure different from the normal shape of the epiglottis and a narrow opening beneath it was seen, and their surrounding tissue presumed to be a pyriform sinus, was observed. After lifting up the epiglottic tip, two lumens were seen through the first opening, which were presumed to be the glottic and esophageal openings. We tried endotracheal intubation using a endotracheal tube with a 6.0 mm inner diameter (ID) and 8.4 mm outer diameter (OD). Because the glottis was not clearly observed and the tube could not easily pass the first opening, we reattempted intubation with a reinforced endotracheal tube 5.5 ID (7.5 OD). We could pass the first opening, but the sliding of the tube tip was performed blindly resulting in esophageal intubation. After failure of the third attempt, we recognized high pressure in the breathing bag even though the saturation was maintained at 100%, so we decided to try orotracheal intubation using a fiberoptic laryngoscope (LF-GP, Olympus, Tokyo, Japan). The first opening was confirmed, and as the fiberoptic laryngoscope was progressed slightly further, the glottic and esophageal opening were confirmed below the first opening. The vocal cords were observed as rudimentary and abnormal in shape, however we tried to slide in a reinforced endotracheal tube (5.5 ID), but the area seemed too tight after advancing 2-3 cm. We changed the tube to a smaller diameter and succeeded in fiberoptic intubation using a reinforced endotracheal tube 5.0 ID (6.9 OD). After the operation, the patient recovered without respiratory difficulty. In the postoperative interview, we found that she had suffered from dysphagia (solid food) since long ago but had not been treated, since the symptoms were not severe. A post operative computed tomography (CT) showed a pharyngeal web covering the laryngeal part of the pharynx on the posterior pharyngeal wall in the upper part of the hypopharynx, with tracheal stenosis below the C6 level of the cricoid area, and upper esophageal wall thickening that extended to mid-esophagus which was suspected of esophageal cancer, accompanied by an elevation in the piriform sinus and esophageal dilatation. Her rigid laryngo scopic examination (Fig. 1) by otorhino laryngologists had a similar review as the one that was found during endotracheal intubation and CT findings. The true glottis and the esophageal opening were observed only after the rigid laryngoscope had passed the first opening that resembled the glottis. The true vocal cord was not developed well, the false vocal cord and pyriform sinus were