J Dent Anesth Pain Med.  2015 Sep;15(3):153-156.

Difficult airway management in a patient with a parapharyngeal tumor

• Ji SM

Abstract

A 47-year-old man was referred to the operating room to treat a dentigenous cyst of the mandibular bone. Initial assessment of the airway was considered normal. However, after the induction of anesthesia, we could not intubate the patient due to severe distortion of the glottis. Fiberoptic bronchoscopy and video laryngoscopy were not effective. Intubation using a retrograde wire technique was successful. After the conclusion of surgery, the patient recovered without any complications. Subsequent magnetic resonance imaging of the patient's neck showed a 6 × 4 × 8.6 cm heterogeneous T2 hyperintense, T1 isointense well-enhancing mass in the prestyloid parapharyngeal space. The patient was scheduled for excision of the mass. We planned awake intubation with fiberoptic bronchoscopy. The procedure was successful and the patient recovered without complications. Anesthetic induction can decrease the muscle tone of the airway and increase airway distortion. Therefore, careful airway assessment is necessary.

Keyword

Awake intubation; Difficult airway; Parapharyngeal tumor

MeSH Terms

Airway Management*
Anesthesia
Bronchoscopy
Glottis
Humans
Intubation
Laryngoscopy
Magnetic Resonance Imaging
Middle Aged
Neck
Operating Rooms

Figure

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  Fig. 1 Panorama view of the patient's jaw shows dentigenous cyst under #48 molar tooth.

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  Fig. 2 The laryngoscopy with C-MAC video laryngoscope showes severely distorted glottis and epiglottis (white arrow).

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  Fig. 3 About 6× 4 × 8.6 cm heterogeneous , T1 isointense well-enhancing mass with central nonenhancing necrotic or hemorrhagic portion, left prestyloid parapharyngeal space. A; sagittal view, B; coronal view, C; axial view.

Reference

1. Varoquaux A, Fakhry N, Gabriel S, Garcia S, Ferretti A, Chondrogiannis S, et al. Retrostyloid parapharyngeal space tumors: a clinician and imaging perspective. Eur J Radiol. 2013; 82:773–782.

2. Bissinger U, Guggenberger H, Lenz G. Retrograde-guided fiberoptic intubation in patients with laryngeal carcinoma. Anesthesia and analgesia. 1995; 81:408–410.

3. Sinha R, Rewari V, Varma P, Kumar A. Successful use of C-Mac video laryngoscope in a child with large parapharyngeal mass. Paediatr Anaesth. 2014; 24:531–533.

4. Gonzalez Enguita R, Obon Monforte H, Romagosa i, Gomez Agraz JL. [Heart arrest during fibrobronchoscopic intubation in a patient with parapharyngeal space neoplasia]. Revista espanola de anestesiologia y reanimacion. 2003; 50:409–413.