Use of light wand as an adjunct during intubation of patient with large epiglottic cyst

provided the original work is properly cited. CC Epiglottic cysts sometimes compromise a patient’s airway, and may make airway management difficult. We report a novel method of intubating a patient with a large epiglottic cyst, using direct laryngoscopy and a light wand. A 53-year-old man with hoarseness was admitted to the hospital. He complained of a mild cough and sore throat for 2 days, without dyspnea. General anesthesia for microscopic laser surgery was planned. Neck computed tomography revealed a nearly non-enhancing cyst, 2.7 × 1.8 × 3.3 cm, located on the right prelingual surface of the epiglottis (Figs. 1A and 1B). In addition to standard monitoring and preparations, we prepared laryngeal mask airways, adult and pediatric fiberoptic bronchoscopes, and an emergency cricothyrotomy kit at the bedside. Two attending anesthesiologists and one resident were present in the operating room. After preoxygenation, propofol 120 mg was given. The patient became unconscious, and we confirmed there was no difficulty with mask ventilation. We then administered rocuronium 25 mg intravenously. After 4 minutes, we attempted intubation with a Macintosh blade no. 3 and 5.0 laser tube (Laser-Flex Tracheal Tube, Mallinckrodt, St. Louis, MO, USA) without stylet. We carefully placed the tip of the Macintosh blade at the vallecula, avoiding direct pressure on the cyst. After that, an assistant held the handle of the laryngoscope steady. The intubating anesthesiologist then held the hockey stick-shaped light wand in the left hand and used it both for leverage and as a light source. Gently elevating both the epiglottis and cyst with the light wand in the upper left direction revealed the lower third of the glottis with sufficient light. We then intubated the patient. After intubation, we began mechanical ventilation with air. Tidal volume was set to 500 ml, respiration rate was 12 per minute, and peak airway pressure was 26 cmH2O. Anesthesia was maintained with sevoflurane 1.5-2.0 vol% and remifentanil continuous infusion of 0.1-2.0 mcg/kg/min. Oxygen saturation was maintained at a minimum of 95% throughout the surgery and in the recovery room. The patient recovered and was discharged after 1 day without any adverse events. Most epiglottic cysts are located on the lingual surface or vallecula, which makes intubation difficult, when a cyst is large. For the treatment of epiglottic cysts, simple aspiration of the cyst results in frequent recurrence, so complete removal is recommended [1]. For this removal, laser surgery seems to be superior to cold instrument surgery, in many respects. During laser surgery, the use of laser resistant endotracheal tubes is recommended to avoid catastrophic airway fires. There are several choices for laser resistant endotracheal tubes, including wrapping metal foil around conventional tubes, Xomed Laser-Shield (Laser-ShieldII Endotracheal Tube, Medtronic Xomed, Jacksonville, FL, USA), and Mallinckrodt Laser-Flex. Inevitably, methods or tubes such as these are accompanied by an increase in the wall thickness of the tubes. With the LaserFlex, for example, the outer diameter (OD) of the tubes is at least 2.5 mm greater than the internal diameter (ID). This number is considerable in comparison to the thickness of conventional tubes, which is 1.3 mm at minimum. In our case, when intubation was attempted, the epiglottic cyst blocked the light from the laryngoscope, so structures behind the cyst were not visible (Fig. 1C). To circumvent this problem, there are several possible options. First, we could use a Miller blade or a Magill blade. Holding the epiglottis from the