Anesthetic management for a patient with severe mento-sternal contracture: difficult airway and scarce venous access -A case report-
A 41-year-old man was hospitalized with severe scar contracture due to flame burn injury to neck and chest three years ago. After undergoing several surgeries, his contracture got worse. He developed severe scar contractures involving neck, face, anterior chest, and both shoulders including upper arms leading to severe deformity. His chin, chest, and both the upper arms were fused together by thick hard scars. Because of the contractures, he had to stay in a stooped posture with no neck flexion or extension. The cervicomental and the mentosternal angles were completely obliterated by thick stiff scars, and the anterior neck structures, including the larynx, the trachea, and the carotid arteries, were not identifiable or palpable ().\nWe consulted an otolaryngologist for airway evaluation, but endoscopic examination of the airway could not be performed because of the narrow external nares and the small oral opening. Preoperative X-rays and a computed tomography (CT) scan for assessing his airway passage and related structures revealed marked thickening of the soft tissues around the neck, without distortion or stenosis of the upper airway and the trachea.\nIn preoperative airway examination, the width from upper incisor to lower teeth was less than 1 cm. Because of the restricted mouth opening, we could not perform modified Mallampati test (mMT). It was difficult to perform face mask ventilation because of nearly fixed neck movement and regressed mandible. For the same reason, conventional laryngoscopic intubation was thought to be impossible. Since the diameter of nares was about 0.5cm, it would be impossible to intubate the patient by nasal approach. So we considered several adjunctive methods, such as fiberoptic bronchoscopy, laryngeal-mask airway, lightwand or a GlideScope® Video laryngoscope, which might be used concomitantly. But there was no available noninvasive approach except orotracheal fiberoptic intubation while the patient is awake, or surgical tracheostomy.\nThe day before the surgery, a peripheral intravenous catheter was placed. Glycopyrrolate 0.2 mg was delivered to the patient via intramuscular injection for reduction of oral secretions just before transferring to operating room. He was placed in the supine position on the operating table with standard monitor. The patient's vital signs were stable and he lay down comfortably on his back by stuffing the gap with pillow and folded sheets. The first attempt of awake fiberoptic intubation was performed after applying topical lidocaine spray to the oral cavity and pharynx. However, it was impossible to intubate with endotracheal tube through restricted mouth opening. Surgical tracheostomy wasn't possible either because thick scar made it impossible to identify the anatomy of the neck. So we decided to perform rapid surgery for release of the neck and mouth contractures under local anesthetic lidocaine (totally 400 mg) to improve his mouth opening by freeing the mandible from the scar. There were no systemic effects such as hypotension, bradycardia, arrhythmia, and seizure.\nInitial scar releasing operation of the mouth and neck was done with intermittent administration of fentanyl (totally 200 mcg). In spite of dissecting nearly the whole circumference of the neck, the mouth opening was only enough to allow passage of the blade of laryngoscope ().\nSince it was impossible to identify glossopharyngeal nerve or superior laryngeal nerve even after releasing the contractures, we could not perform nerve block. After applying topical lidocaine spray to the oral cavity and pharynx, orotracheal intubation with a cuffed endotracheal tube (7.0 mm ID) was performed with the use of fiberoptic bronchoscopy under GlideScope® Video laryngoscope guidance (). There was no difficulty during the intubation. We confirmed the tube passing through the vocal cord and then it was fixed at mouth angle.\nAfter the surgery, the patient remained with endotracheal tube and was transferred to surgical intensive care unit.\nHe received continuous infusion of midazolam and vecuronium for sedation and mechanical ventilation was maintained. Postoperative day 2, sedation was stopped and extubation was accomplished. After it, his spontaneous breathing was regular, chest movements were good. There was no hoarseness. Postoperative day 3, the patient was moved to the general ward.