Anesthetic management of a patient with Montgomery t-tube in-situ for direct laryngoscopy
A 60 kg, 23-year-old man was scheduled for DL assessment and further surgery. The patient had t-tube insertion done earlier for subglottic stenosis resulting as a complication of prolonged intubation and tracheostomy tube (TT) insertion, following head injury. The t-tube was needed, as 70° endoscopy had revealed the presence of a web between true and false vocal cords, which had reduced the glottis chink. All the relevant investigations were within normal limits.\nThe patient's upper airway was anesthetized by 10% lignocaine viscus gargles and nebulization of 6 ml 4% lignocaine, using a tight fitting mask and standard nebulizer. Glycopyrrolate 0.2 mg was administered intramuscular as an antisialagogue.\nAfter shifting the patient to OT, intravenous (IV) access was secured and standard monitors were applied. A No. 4 endotracheal tube (ET) connector was found to fit into the extraluminal limb of t-piece. Patient was preoxygenated with 100% oxygen through the Bain's circuit connected to the extraluminal limb of t-tube with the ET connector and capnometer sampler attached. Patient was administered IV ranitidine 50 mg, metoclopramide 10 mg, midazolam 1 mg and fentanyl 100 mcg slowly. Anesthesia was induced by inhalation of 3-4% sevoflurane in 100% oxygen on spontaneous breathing and was maintained with 2-3% sevoflurane in oxygen and nitrous oxide mixture (50:50).\nAfter ensuring adequate ventilation and depth of anesthesia, DL assessment was started without any significant change in hemodynamic parameters. During the procedure, surgeons blocked the upper open intraluminal end of the t-tube with a piece of ribbon gauze, sufficient to prevent air leak without compromising surgical view. The rest of the procedure was performed satisfactorily on assisted spontaneous breathing with minimal leakage of gas through upper open end.\nAt the end of procedure the ribbon gauze was removed from the upper end of t-tube. The anesthetic gases were discontinued and 100% oxygen was administered. The patient became conscious, was breathing adequately through the t-tube and maintaining oxygen saturation of 99% on room air. Patient was shifted to the recovery room with stable vital parameters.