Eugenio Martínez Hurtado, MD
Ana Tirado Errazquin, MD
Paloma Muñoz Saldaña, MD
Elena Saez Ruiz, MD
Norma Aracil Escoda, MD
Infanta Leonor University Hospital
Miriam Sánchez Merchante, MD
Alcorcón Foundation University Hospital
Laryngeal cysts are infrequent, usually benign casual findings during laryngeal exploration. They can be classified according to their size, location, content, and relation to the laryngeal mucosa. Ductal cysts, which are formed by distended glandular ducts clogged by mucous retention, represent 75% of cases. The remaining cases are saccular cysts that can cause respiratory symptoms.1
We present a case of difficult intubation and its management in a patient scheduled for excision of a giant asymptomatic vallecular cyst.
The patient was a 40-year-old man. He weighed 97 kg and was 186 cm tall. He smoked 20 cigarettes per day until 2 months prior. He sought medical advice for dysphonia and was sent to an otolaryngologist for a cystic lesion in the hypopharynx.
Fibrolaryngoscopy showed a large cystic lump that seemed to come from the right side of the vallecula. The lump completely compressed the epiglottis and prevented access to the vocal cords. We were only able to see the piriform sinus (Figure 1). The patient had no dyspnea or dysphagia.
A computed tomographic scan of the neck showed a hypodense lesion measuring 22x31x17 mm with well-defined edges and many millimetric calcifications within. The hypopharynx was occupied by the lesion contacting the upper side of the epiglottis, which was compressed.
The first diagnostic option was a giant epiglottic cyst. The patient underwent consultation for laryngeal microsurgery for cyst excision. We also explained to the patient about a possible tracheotomy in case of impossible intubation. The patient asked for every possible attempt to avoid a tracheotomy.
The patient had no drug allergies or other medical history. In airway assessment, he had a Mallampati class III score, interdental distance above 5 cm, thyromental distance above 6 cm, and normal neck extension. The result of Arné et al’s multivariate test was 11.2 Assessment of difficult mask ventilation was made with Kheterpal et al’s score.3 We found 2 of 5 risk factors: male sex and Mallampati class III score. An assessment of difficult mask ventilation and difficult intubation found 3 of 12 risk factors described by Kheterpal et al: male sex, Mallampati class III score, and presence of dentition.4 Therefore, difficult mask ventilation after general anesthesia induction was not suspected.
Balanced general anesthesia was performed with standard monitoring: electrocardiography, bispectral index, noninvasive blood pressure monitoring, pulse oximetry, and capnography. After 5 minutes of preoxygenation, induction was performed with 2 mg/kg of propofol, 2.5 mcg/kg of fentanyl, and 1.2 mg/kg of rocuronium. We monitored neuromuscular blockage (NMB) with the TOF-Watch (Organon Laboratories Ltd). Sugammadex (16 mg/kg) was available, if needed.
Adequate mask ventilation was checked under deep NMB. We attempted 3 intubation approaches:
Plan A: Two anesthesiologists attempted intubation with the Pentax AWS-S100 video laryngoscope. We tried to raise the epiglottis with the blade, according to the manufacturer’s recommendations, but failed to see the glottis as a result of cystic compression.
Plan B: Mask ventilation was still easy to make a new attempt with the King Vision video laryngoscope (Ambu). We failed to intubate after 2 attempts; the second attempt was with an extraglottic device (Frova, Cook Medical) inside the endotracheal tube.
Plan C: The patient was still easy to ventilate, so we made a new intubation attempt using an aScope (Ambu) single-use flexible intubation scope. We were not able to move the cystic lesion, so we could not intubate.
We decided to wake the patient and delay surgery. We used 1.5 g of sugammadex (16 mg/kg) and 80 mg of methylprednisolone. We extubated the patient when his train-of-four ratio was above 0.9. The patient remained on oxygen saturation levels above 95% throughout the process, and mask ventilation was easy each time. He was transferred to the post-anesthesia care unit with supplementary oxygen when he regained consciousness and spontaneous breathing.
Vallecular cysts, especially giant ones, can lead to a situation in which the patient cannot be intubated or ventilated with a face mask, making it necessary to resort to a surgical airway entry, as supraglottic devices will not solve supraglottis-related problems.5 In this case, it was easy to ventilate the patient with a face mask, achieving oxygen saturation levels above 95% at all times. However, ventilation can be difficult or impossible in some cases due to obstruction of the airway by the mass.6,7 Other devices such as the Combitube (Tyco-Kendall-Sheridan) or EasyTube (EzT) could not serve as rescue since they are designed for blind placement and could cause rupture of the cyst.
Repeated attempts to make direct laryngoscopy should be avoided to prevent rupture, hemorrhage, and edema, as well as other comorbidities.8 When difficult airway management is suspected, the recommendation is to perform a maximum of 3 tracheal intubation attempts in an induced patient.9 However, recent guidelines of the UK Difficult Airway Society (DAS) recommend a maximum of 4 attempts.10
When we consider intubation of a patient with planned difficult airway scenarios, we must decide whether to wake the patient after induction of general anesthesia. We should consider, in addition to the predictors, other issues concerning the patient or the context of the intervention, such as apnea time, risk for aspiration, presence of obstructive disease of the airway, skill and experience of the anesthesiologist, availability of help, etc. Intubation of an induced patient with a suspected difficult airway should only be considered if the safety margin is the same as in an awake patient.9 In our case, we did not expect difficult ventilation of the patient, have enough experience in handling various devices in the operating room, and personnel are trained in handling difficult airway scenarios.
Therefore, we followed the recent DAS guidelines and adopted a sequential approach to managing the patient after he was induced. These guidelines were applied on the basis of what was learned from NAP4 (4th National Audit Project) about major complications in airway management,11 providing a sequential series of action plans that can be used when tracheal intubation fails, in which the oxygenation of the patient is prioritized, limiting the number of collisions on the airway in order to minimize trauma and complications.10
Mask ventilation is a key element of airway management. In fact, the impossibility to establish a secure airway is associated with important complications only when ventilation is compromised. In 2000, Langeron published a study that determined 5 independent risk factors, which were confirmed in a subsequent study of 22,660 by Kheterpal et al in 2006, except for the absence of dentition.3 Through logistic regression analysis, Kheterpal et al established 5 predictors of impossibility of mask ventilation: cervical post–radiation therapy changes, male sex, obstructive sleep apnea, Mallampati class III-IV, and presence of a beard.3 There is currently no specific test for predicting difficult mask ventilation.
Furthermore, in 2013, Kheterpal et al analyzed the combined existence of difficult ventilation with difficult intubation, noting that the association of manual ventilation and difficult intubation occurred in 0.4% of 176,679 adult patients (1/250).4 Data from this study represent the first empirical guide for predicting difficult manual ventilation with difficult intubation, finding that 12 of the analyzed predictors demonstrated statistical significance: male sex, body mass index >30 kg/m2, reduced thyromental distance, Mallampati class III-IV, presence of a beard, sleep apnea/hypopnea, presence of dentition, limited cervical extension, jaw protrusion, thick neck, cervical changes post-radiation therapy, and cervical mass.4
We chose indirect laryngoscopy with the Pentax AWS–S100 as our initial approach because this is a video laryngoscope in which its manufacturer recommends performing a Miller maneuver type to lift the epiglottis, which we thought would help us achieve intubation. As a rescue (plan B), we prepared a King Vision video laryngoscope with a channeled blade and the aScope video fiberscope (plan C). Finally, we decided to wake the patient versus neck surgical access in case we could not maintain oxygenation.
Video laryngoscopes allow a view of the entrance of the glottis, which is independent of the line of sight, especially those with angled blades, which in practice means a Cormack-Lehane (CL) grade 1 or 2 (CL 1/4 or 2/4) in 99% of cases.12 However, achieving CL grade 1 (CL 1/4) with a video laryngoscope does not guarantee the success of the intubation. We experienced difficulties in visualizing the glottis and were unable to achieve intubation despite repeated attempts with various optical devices.
Although we were unable to intubate the patient with the 3 optical devices described, the patient was reprogrammed and subsequently intubated awake without incident with the aScope in the sitting position.
We believe this approach is more effective in an awake patient. However, we believe video laryngoscopes are still useful in these types of patients because the difficult airway is the result of the dynamic interaction between the anatomy and functional factors.13
Although direct laryngoscopy with a Macintosh blade is the gold standard for intubation in an induced patient, video laryngoscopy has been accepted by the two most prestigious difficult airway societies in the world: the American Society of Anesthesiologists14 and DAS. Both societies have been a source of indisputable support for the role of these devices in difficult airway scenarios today, and all anesthesiologists should be trained in their use and should have immediate access to them. In addition, the 2015 British guidelines have positioned them in plan A boarding, because they offer a better view compared with conventional direct laryngoscopy and, in daily practice, represent the first choice of many anesthesiologists.10
Finally, vallecular cysts also can be incidentally found during intubation for other surgical procedures, which may represent situations of unexpected difficult airway management.15-17 In these cases, such cysts have a high risk for bleeding if vascularized, and aspirating their content to facilitate the intubation18 is a possible approach to the airway. If access to optical devices is available, wake and schedule the patient for awake intubation or surgical access airwa y.
Joint assessment by anesthesiologists and otolaryngologists is essential to choose the best approach19 to a vallecular cyst, especially of these dimensions. Proper handling of the airway is required in these patients to avoid possible cyst manipulation, as they are often friable, vascularized, and bleed easily. A difficult airway with difficult ventilation and/or intubation should always be considered.
Dr Hurtado is professor of the course “Management of the Difficult Airway and Handling of the Fiberoptic Bronchoscope” at AnestesiaR.org and IDEhA (Virtual Simulation and Training Center for Health Teaching).
DeSanto LW, Devine KD, Weiland LH. Cysts of the larynx—classification. Laryngoscope. 1970;80(1):145-176.
Arné J, Descoins P, Fusciardi J. Preoperative assessment for difficult intubation in general and ENT surgery: predictive value of a clinical multivariate risk index. Br J Anaesth. 1998;80(2):140-146.
Kheterpal S, Martin L, Shanks AM, et al. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009;110(4):891-897.
Kheterpal S, Healy D, Aziz MF, et al. Incidence, predictors and outcome of difficult mask ventilation combined with difficult laryngoscopy. A report from the multicenter perioperative outcomes groups. Anesthesiology. 2013;119(6):1360-1369.
Hurtado EM, Merchante MS, Saldaña PM, et al. VLM TotalTrack® use in a large cystic lesion in left arytenoepiglottic fold: a case report and review of literature. Presented at: World Airway Management Meeting; November 12-14, 2015; Dublin, Ireland. Poster 339.
Kothandan H, Ho VK, Chan YN, et al. Difficult intubation in a patient with vallecular cyst. Singapore Med J. 2013;54(3):e62-e65.
Reiersen DA, Gungor AA. Airway management in an infant with a giant vallecular cyst. Am J Otolaryngol. 2014;35(2):261-264.
Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99(2):607-613.
Law JA, Broemling N, Cooper RM, et al. The difficult airway with recommendations for management—part 2—the anticipated difficult airway. Can J Anaesth. 2013;60(11):1119-1138.
Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-848.
Cook TM, Woodall N, Frerk C, et al. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011;106(5):617-631.
Cook TM. A new practical classification of laryngeal view. Anaesthesia. 2000;55(3):274-279.
Mosier JM, Joshi R, Hypes C, et al. The Physiologically Difficult Airway. West J Emerg Med. 2015;16(7):1109-1117.
Practice Guidelines for Management of the Difficult Airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118:251-270.
Vorobeichik L, Hare GM, Zirkle M, et al. Airway management of incidental vallecular cysts in adults. A A Case Rep. 2015;5(12):223-227.
Rivo J, Matot I. Asymptomatic vallecular cyst: airway management considerations. J Clin Anesth. 2001;13(5):383-386.
Lee DH, Yoon TM, Lee JK, et al. Clinical characteristics and surgical treatment outcomes of vallecular cysts in adults. Acta Otolaryngol. 2015;135(11):1185-1188.
Yuce Y, Uzun S, Aypar U. Asymptomatic vallecular cyst: case report. Braz J Anesthesiol. 2013;63(5):419-421.
Torun MT, Seçkin E, Tuncel ü, et al. A rare entity: adult asymptomatic giant vallecular cyst. Case Rep Otolaryngol. 2015;2015:723420.