A 65-year-old woman (height: 149 cm, body weight: 48kg) was scheduled to undergo a video-assisted thoracoscopic esophagectomy for esophageal cancer. She had been diagnosed with tongue cancer and had undergone right hemiglossectomy with flap reconstruction of the tongue using a femoral skin flap 9 years previously at another hospital (Fig. 1). At the preoperative anesthesia visit, the difficult airway and difficult ventilation risks were assessed. During the first minutes, the patient laid in the supine position without respiratory distress. We confirmed that she could lie in the supine position for tens of minutes while awake. Her mouth opening or neck extension were not limited, with Mallampati class II and upper lip bite test class I [2, 3]. Preoperative images during gastrointestinal endoscopy (Fig. 2) and computed tomography (Fig. 3) revealed that no anatomical anomalies or changes were found in the glottis, epiglottis, or epiglottis vallecula.
After gathering preoperative information on airway management, we predicted difficult intubation without difficult mask ventilation and no increased risk of aspiration, increased risk of rapid desaturation, or suspected emergency invasive airway. Therefore, we did not plan awake intubation. The airway management was planned as follows: (1) anesthesia induction with neuromuscular blockade; (2) intubation using a McGrath® video laryngoscope (Aircraft Medical, Edinburgh, Scotland) with a size 4 blade because the estimated distance from the teeth to the vallecula was >11 cm, followed by fiberoptic intubation with or without Airway Scope® (AWS; Pentax, Tokyo, Japan). Moreover, the surgeon found no anomalies or changes in the pharynx during the preoperative gastrointestinal endoscopy before anesthesia.
Oxygen was administered at a flow rate of 6 L/min. Then, a continuous infusion of remifentanil at 0.3 μg/kg/min was started with a bolus of 100 μg fentanyl. After the patient experienced a floating sensation, 80 mg of propofol was administered. As mask ventilation was successfully performed, a bolus of 50 mg of rocuronium was administered. Subsequently, we performed video-laryngoscopy. Poor mobility of the reconstructed tongue did not allow pushing the tongue aside using the McGrath® blade. Because the Cormack and Lehane laryngeal view remained at grade 4 with the backward–upward–rightward pressure maneuver, we terminated the first attempt of laryngoscopy. Desflurane 2% in 100% oxygen was administered and the remifentanil infusion rate was changed to 0.2 μg/kg/min. In the second and third attempts, we tried fiberoptic intubation using the AWS. However, we failed to find the epiglottis and esophagus using fiberoptic bronchoscopy. On the fourth attempt, a fiberoptic bronchoscopy was inserted into the left nasal cavity through a tracheal tube. We were unable to insert the bronchoscopy into the hypopharynx because we could not move the bronchoscope forward. Additionally, the McGrath® was inserted into the oral cavity. However, we only identified edematous mucous membranes in the larynx and were unable to locate the epiglottis. As the peripheral oxygen saturation decreased, we interrupted the intubation procedure and performed two-person mask ventilation. The lowest peripheral oxygen saturation level was 92%. Meanwhile, the surgeons advised that they could observe both the glottis and epiglottis during gastrointestinal endoscopy in the left-lateral position. The patient was then moved from the supine to the left-lateral position. Fiberoptic intubation via the nasal cavity was attempted again. Although an edematous membrane was observed in the larynx, a narrow gap was observed on the distal side of the epiglottis-like edematous structure. After moving the fiberoptic bronchoscope into the gap, the normal glottis, ring-shaped tracheal cartilage, and tracheal bifurcation were finally identified. The tracheal tube was smoothly intubated using a bronchoscopy guide. Post-surgery, the patient was admitted to the intensive care unit under sedation and mechanical ventilation with tracheal intubation.
The following morning, the patient’s trachea was carefully extubated using the following procedure: (1) the patient was positioned in the left-lateral position, (2) a fiberoptic bronchoscope was inserted into the tracheal tube, (3) the trachea was extubated with the bronchoscope remaining in the trachea, and (4) the glottis, epiglottis, and epiglottis vallecula were observed using bronchoscopy. During this procedure, no edematous membrane was observed in the pharynx. After extubation, the glottis shifted to the ventral side and upper airway stenosis and obstruction were not observed.
After the patient clearly recovered, we asked her whether she could sleep in the supine position before and after the hemiglossectomy. She answered, “I always sleep in the lateral position. If I sleep in the supine position, I wake up because of airway obstruction. This did not happen before my hemiglossectomy.” She retained no memory from the anesthesia induction.