Acta Anaesthesiologica Taiwanica 51 (2013) 180e183

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Case Report

Difficult fiber-optic intubation in a patient with giant neck masses:

The role of McCoy laryngoscope in elevating compressed laryngeal
aperture
Lijen Yeh, Hung-Shu Chen*, Ping-Heng Tan, Ping-Hsin Liu, Shao-Wei Hsieh,
Kuo-Chuan Hung
Department of Anesthesiology, E-Da Hospital, Kaohsiung, Taiwan, ROC

a r t i c l e i n f o a b s t r a c t

Article history: Airway management in patients with giant neck masses is usually a challenge to anesthesiologists. A
Received 5 January 2013 giant neck mass could compress the airway and thus impede endotracheal intubation. We encountered a
Accepted 5 September 2013 situation where the giant neck masses of a patient pushed the epiglottis posteriorly toward the posterior
pharyngeal wall and compressed the laryngeal aperture narrowing after anesthetic induction, causing
Key words: direct laryngoscopic intubation and sequential fiber-optic intubation failed. The neck masses twisted the
fiber optic technology;
aryepiglottic fold tortuously and clogged the laryngeal aperture tightly, making a flexible fiber-optic
intubation, intratracheal: difficult;
bronchoscope unable to pass through the laryngeal aperture. Later, we utilized a McCoy laryngoscope
laryngoscopes: McCoy;
neck: mass
alternately to lift the compressed larynx up and away from the posterior pharyngeal wall, creating a
passage and completing endotracheal intubation successfully with the aid of a gum elastic bougie. Our
case suggested that the tilting tip blade of the McCoy laryngoscope could lever the tongue base up
against the tumor mass compression to improve laryngeal views and facilitate endotracheal intubation
when a difficult fiber-optic intubation was encountered on a compressed laryngeal aperture.
Copyright Ó 2013, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights
reserved.

1. Introduction laryngoscopic forces could not elevate the epiglottis anymore.6

Herein, we report a patient whose giant neck masses narrowed
Difficult airway is a challenging condition for anesthesiologists, the laryngeal aperture and defeated fiber-optic intubation, and who
especially when it coincides with giant neck masses. Neck masses was successfully intubated by the McCoy laryngoscope with a gum
of different origins may distort the airway anatomy, making airway elastic bougie in an emergency scenario.
management difficult and endangering the patient’s safety.1,2 Use
of a fiber-optic bronchoscope has been considered to be an effective
2. Case report
and safe method to intubate patients with difficult airway.3 How-
ever, fiber-optic intubation may become extremely difficult in the
A 71-year-old male was scheduled to undergo surgical excision
situation of a distorted airway, or when fiberscopic views are
for his large neck masses. He was 163 cm tall and weighed 61 kg.
obscured, by e.g., massive hematemesis or plentiful sputum. When
The masses were irregularly ovoid in shape, estimated at 12e16 cm
effective mask ventilation is guaranteed, direct laryngoscopy with a
in diameter, and circumvented his whole anterior neck (Fig. 1). He
short acting muscle relaxant remains a practical option for tracheal
denied vocal hoarseness, dyspnea on exertion, or dysphagia. Neck
intubation, even in patients with a potentially difficult airway.4 The
computed tomography revealed tracheal deviation to the right, due
McCoy levering laryngoscope has been well recognized as a useful
to the external compression of the giant neck masses (Fig. 2). Pre-
tool for certain cases of difficult intubation.5,6 The advantages of the
operative airway examination showed a full mouth opening and
levering laryngoscope are that it improves direct vision of the lar-
adequate neck extension with a conclusion of Mallampati Class 2.
ynx and expands the laryngeal aperture room when regular
Because of concern regarding the possibility of a compromised
airway and difficult intubation, we informed the patient of the
Conflicts of interest: The authors declare that they have no conflicts of interest.
* Corresponding author. Department of Anesthesiology, E-Da Hospital, 1, Yi-Da
necessity of awake fiber-optic intubation via the nostrils. However,
Road, Jiau-shu Tsuen, Yan-chau Shiang, Kaohsiung County, Taiwan, ROC. he strictly refused awake intubation out of fear, even though we
E-mail address: ed104282@edah.org.tw (H.-S. Chen). advised him of the risks and even death. To comply with the

1875-4597/$ e see front matter Copyright Ó 2013, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.aat.2013.10.001
McCoy blade for difficult fiber-optic intubation 181

Fig. 1. Giant masses located at the left anterior neck in (A) the lateral view and (B) the anterior view.

request of the patient, the attending anesthesiologist attempted elastic bougie, and a combined approach of direct laryngoscopy and
intubation under general anesthesia with direct laryngoscopy. fiber-optic intubation were tried sequentially, but failed. The pa-
The patient was positioned in the sniff position, under standard tient’s neck masses hindered both the BURP maneuver and assis-
monitoring. A fiber-optic bronchoscope, McCoy laryngoscope, and tant jaw thrust. Fiberscopic examination disclosed that the neck
other airway instruments were available nearby in the operating masses pushed the tongue base downward, and the laryngeal
room. His oxygen saturation was 99% on room air. After preox- structure and the epiglottis posteriorly against the posterior
ygenation with pure oxygen for 5 minutes, anesthetic induction pharyngeal wall, thus obscuring the laryngeal aperture. Meanwhile,
was done with intravenous fentanyl 100 mg, 2% lidocaine 40 mg, the encircling neck masses deformed the aryepiglottic fold tortu-
and propofol 140 mg. Manual breathing was adequately main- ously and clogged the laryngeal aperture tightly, making the fiber-
tained by mask ventilation following the induction agents, and then optic bronchoscope unable to pass through the compressed
succinylcholine 90 mg was given intravenously for muscle relaxa- laryngeal opening. Occasionally, the flexible fiberscope was able to
tion. Under complete muscle relaxation, direct laryngoscopic pass through the vocal cords, but frustratingly the endotracheal
intubation with a Macintosh Number 3 blade (Welch. Allyn Inc., tube could not work its way beneath the glottis, due to tough
Onondaga County, NY, USA) was attempted. Despite the maximum resistance of the collapsed laryngeal structure. Finally we imple-
lifting effort, the anesthesiologist could only see a drooping mented a McCoy laryngoscope (Truphatek International Ltd,
epiglottis. External laryngeal manipulation was impeded by his Netanya, Israel) to conduct intubation, utilizing its tilting tip to
giant tumor. Several attempts of direct laryngoscopic intubation by lever the collapsed larynx upward against the tumor’s compres-
two experienced anesthesiologists failed. Endotracheal intubation sion, to push the compressed lateral laryngeal walls outward, and
assisted with the backward, upward, and rightward pressure to create an extra space to get a glimpse of the arytenoid cartilages.
(BURP) maneuver on the larynx and a gum elastic bougie, fiber- This key glimpse enabled us to probe the gum elastic bougie to the
optic intubation through the nostrils, blind intubation with a gum vocal cords and deliver an endotracheal tube into the trachea. No

Fig. 2. Computed tomography images of the upper airway showed (A) right-sided tracheal deviation and (B) the narrowest portion of the trachea (the arrow indicates absent
narrowing of the tracheal lumen).
182 L. Yeh et al.

significant resistance was encountered while passing the endotra- from the operation without significantly adverse sequelae and was
cheal tube into the trachea and the correct tracheal tube position discharged on the 4th postoperative day.
was confirmed by an auscultation and end-tidal capnography.
After the successful endotracheal intubation, general anesthesia 3. Discussion
was maintained with 3% sevoflurane in oxygen. Cisatracurium
10 mg was given sequentially for surgical relaxation. The lungs Many cases of failed intubation occur when “difficult airways”
were ventilated at a tidal volume of 8 mL/kg and a rate of 12 are not recognized before the initiation of general anesthesia. A
breathes/minute; the peak airway pressure ranged from 18 mmHg careful airway evaluation must be done and reassured routinely
to 22 mmHg. The perioperative course went uneventfully, and the before an anesthetic induction. A difficult airway could be caused
patient was extubated under a full recovery from the general by any large neck mass, such as an enlarged thyroid tumor, or a
anesthesia. Postoperatively, he complained only of wound pain and deep neck infection, which produces a tracheal deviation,
a sore throat in the postanesthesia care unit, which were treated by compression, or both. Bouaggad et al conducted a prospective study
intravenous morphine 5 mg. He did not have dyspnea post- to evaluate the risk factors of difficult intubation in the presence of
operatively. Pathology of the neck tumors showed a papillary thy- thyroid goiter, concluding that cancerous goiter and Cormack Grade
roid carcinoma with focal cystic degeneration. He recovered well III or IV were significantly associated with difficult intubation.7

Fig. 3. Algorithm of airway management for patients with giant neck masses.
a
If the drooping tongue blocks the way of the fiberscope, we suggest elevating the obstacle with forceps, a blocker, or even the blade of a laryngoscope.
McCoy blade for difficult fiber-optic intubation 183

Cancerous goiter is usually associated with tissue fibrosis, which on the spot of the vallecula, thus the epiglottis can be effectively
may immobilize the laryngeal structures and hinder the laryngo- lifted away from the posterior pharyngeal wall to expose the larynx
scopic views. In this case, postoperative pathology revealed papil- further, even against the overlying tumor’s compression.6 The
lary thyroid carcinoma. Therefore, the presence of a full mouth specific distribution and contour of the giant neck masses in this
opening and adequate neck extension in the preoperative airway case was strongly associated with the lack of preoperative warning
evaluation still cannot exclude a difficult intubation with conven- predictors of difficult intubation and unforeseen occurrence of
tional laryngoscopy. Furthermore, although the size of a goiter was epiglottis drooping and laryngeal aperture collapse. It was
not an absolute risk factor of difficult intubation,7 a giant neck mass demonstrated in the patient presented in our report that the McCoy
itself could hamper the application of either the external laryngeal laryngoscope could facilitate successful intubation in an emergency
pressure, BURP maneuver or jaw thrust,8 and make it more difficult situation, when facing a comatose patient whose airway is
for anesthesiologists to obtain adequate laryngeal views. compromised with huge neck masses, or who rejects awake intu-
Difficult tracheal intubation accounted for approximately 17% of bation (Fig. 3). The McCoy laryngoscope provides a crucial boost in
adverse respiratory events for surgical patients in a closed-claims improving the laryngeal view and helps to complete tracheal
analysis, executed by the American Society of Anesthesiologists.9 intubation in the situation of difficult fiber-optic intubation.
The Difficult Airway Society has developed guidelines for man- It is concluded that giant neck masses do not necessarily show
agement of difficult tracheal intubation in non-obstetric adults adverse predictors during preoperative airway evaluation. Caution
without upper airway obstruction.4 An increased incidence of should be taken when difficult intubation could be encountered,
morbid nonfatal events has also been noted in patients who have due to a tortuously distorted airway, slumped tongue base and
difficult tracheal intubation. Although several studies have pre- compressed laryngeal space after anesthetic induction. In a
dicted a difficult airway with variants predicting factors success- particular scenario of giant neck masses combined with a collapsed
fully, a wide disparity was discovered in the diverse sensitivities of laryngeal aperture, the McCoy laryngoscope may be a useful tool in
the different models, which nevertheless resulted in occasional providing a levering force for raising the tongue base against tumor
failure of predicting a difficult airway or difficult intubation weight and offering an improved view of the larynx for facilitating
beforehand.1,7 endotracheal intubation.
According to the intubation difficulty scale, this patient did not
actually fulfill many criteria of difficult intubation, such as inade-
quate month opening, limited neck extension, or unfavorable de- Acknowledgments
gree of Mallampati classification.1 In addition, there was no tracheal
narrowing found in the neck computed tomography. As the patient Funding sources supporting the submitted work include the
refused fiber-optic nasal intubation due to fear, we considered that Department of Anesthesiology, E-Da Hospital.
conventional direct laryngoscopy may be feasible if the mask
ventilation was secure.4 Unfortunately a conventional Macintosh References
laryngoscope blade could not lift the vallecula up, because the
surrounding papillary carcinoma increased the soft tissue stiffness 1. Adnet F, Borron SW, Racine SX, Clemessy JL, Fournier JL, Plaisance P, et al. The
and anchored the laryngeal structure on the neighboring connec- intubation difficulty scale (IDS): proposal and evaluation of a new score
characterizing the complexity of endotracheal intubation. Anesthesiology
tive tissue. Also, the giant mass displaced the laryngeal structure 1997;87:1290e7.
further and pushed the epiglottis to a position where it blocked the 2. McHenry CR, Piotrowski JJ. Thyroidectomy in patients with marked thyroid
laryngeal aperture, resulting in difficulty of fiber-optic probing. We enlargement: airway management, morbidity, and outcome. Ann Surg 1994;60:
586e91.
expected that fiber-optic intubation would not become easier
3. Langford RA, Leslie K. Awake fibreoptic intubation in neurosurgery. J Clin
whether the patient was kept awake or sedated under intravenous Neurosci 2009;16:366e72.
anesthetics. 4. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines
Awake fiber-optic intubation with a flexible fiberscope is the for management of the unanticipated difficult intubation. Anaesthesia 2004;59:
675e94.
gold standard for an anticipated difficult intubation, especially 5. Tuckey JP, Cook TM. An evaluation of the levering laryngoscope. Anaesthesia
when complicated with a compromised airway.10e12 In our patient, 1996;51:71e3.
an alternative method using a levering laryngoscope was chosen 6. Aoyama K, Nagaoka E, Takenaka I, Kadoya T. The McCoy laryngoscope expands
the laryngeal aperture in patients with difficult intubation. Anesthesiology
instead of a flexible fiberscope, because the bronchoscope tip was 2000;92:1855e6.
blocked by the drooping tongue and distorted laryngeal anatomy. 7. Bouaggad A, Nejmi SE, Bouderka MA, Abbassi O. Prediction of difficult tracheal
Additionally, the BURP maneuver and assistant jaw thrust were intubation in thyroid surgery. Anesth Analg 2004;99:603e6.
8. Vasudevan A, Venkat R, Badhe AS. Optimal external laryngeal manipulation
impeded by the giant neck masses. Asai and Shingu stated that the versus McCoy blade in active position in patients with poor view of glottis on
paucity of the normal anatomical space between the posterior direct laryngoscopy. Indian J Anaesth 2010;54:45e8.
pharyngeal wall and the larynx, was a typical reason to lose out 9. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in
anesthesia: a closed claims analysis. Anesthesiology 1990;72:828e33.
endotracheal intubation when a flexible fiberscope was used.13 10. Thierbach AR, Werner C. Infraglottic airway devices and techniques. Best Pract
Furthermore, the fiberscope was not strong enough to guide an Res Clin Anaesthesiol 2005;19:595e609.
endotracheal tube into the trachea in the context of a severely 11. Dabbagh A, Mobasseri N, Elyasi H, Gharaei B, Fathololumi M, Ghasemi M, et al.
A rapidly enlarging neck mass: the role of the sitting position in fiberoptic
distorted airway.14 Excessive force exerted during intubation may
bronchoscopy for difficult intubation. Anesth Analg 2008;107:1627e9.
injure the glottic tissue or break the flexible bronchoscope. 12. Ovassapian A. Fiberoptic endoscopy and the difficult airway. 2nd ed. Philadel-
The McCoy laryngoscope has been reported to improve laryn- phia: Lippincott-Raven Press; 1996.
geal views in patients with difficult intubation.5,6 The McCoy 13. Asai T, Shingu K. Difficulty in advancing a tracheal tube over a fibreoptic
bronchoscope: incidence, causes and solutions. Br J Anaesth 2004;92:870e81.
laryngoscope is designed to fulcrum its tilting blade tip within the 14. Wulf H, Brinkmann G, Rautenberg M. Management of the difficult airway. A
pharynx and to concentrate the levering force of the blade tip right case of failed fiberoptic intubation. Acta Anaesthesiol Scand 1997;41:1080e2.