An 83-year-old woman (height = 155 cm; bodyweight = 55 kg) had undergone radiotherapy (66 Gy) for hypopharyngeal cancer 16 years previously. Cancer recurrence was found, and tumor resection using direct laryngoscopy was scheduled. Physical examination 1 day before surgery did not reveal findings that suggested a DA, only previous radiotherapy. Fibrotic changes in the neck, restriction of neck flexion, hoarseness, or difficulty in swallowing were not observed. The image of preoperative computerized tomography scan around the epiglottis did not indicate any abnormalities which we might suspect DA. However, preoperative flexible fiberoptic laryngoscopy showed a supraglottic change (Fig. 1a).
The airway was open, and we assessed the risk of difficulty in ventilation and intubation to be low. Anesthesia was induced with propofol and remifentanil, and then, rocuronium was administered. Mask ventilation did not pose problems. During intubation, to obtain a clear view of the vocal cords (VCs), the epiglottis was pulled upwards by a video laryngoscope (McGRATH®; Aircraft Medical, Edinburgh, UK). Supraglottic hyperplasic cicatricial tissue was also pulled up and interfered with the VC view, and a narrowed airway hampered intubation with an endotracheal tube (internal diameter (ID) = 6.0 mm) (Fig. 1b). We tried again without pulling up the epiglottis and then intubated with a microlaryngeal endotracheal tube (ID = 5.0 mm; Covidien, Dublin, Ireland). Intubation was completed with second attempts of laryngeal exposure, and desaturation was not observed during intubation. The operation was trouble-free, and she was discharged from hospital on postoperative day 6.