Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 47  |  Issue : 2  |  Page : 122-125

Managing the airway of acid burn contracture of the neck in a 12-year-old girl


Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha 'O' Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission14-Mar-2020
Date of Acceptance12-Jun-2020
Date of Web Publication11-Sep-2020

Correspondence Address:
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha 'O' Anusandhan University,Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_19_20

Rights and Permissions
  Abstract 


Managing the airway of patient with postburn contracture at the neck is often challenging for otolaryngologists and anesthesiologists. It affects the oro-pharyngo-laryngeal airway axes because of anatomical and functional deformities because of the long-standing contracture in the face and neck region. We present a case of extensive neck postburn contractures distorting anatomy, whose airway was assessed and managed using a video fiberoptic bronchoscope (FOB) (Ambu® aScope™). Our experience of the utility of FOB mirrors the experience and literature in the management of difficult airway.

Keywords: Airway, flexible video bronchoscope, neck, postburn contracture


How to cite this article:
Swain SK, Shajahan N. Managing the airway of acid burn contracture of the neck in a 12-year-old girl. J Sci Soc 2020;47:122-5

How to cite this URL:
Swain SK, Shajahan N. Managing the airway of acid burn contracture of the neck in a 12-year-old girl. J Sci Soc [serial online] 2020 [cited 2020 Oct 31];47:122-5. Available from: https://www.jscisociety.com/text.asp?2020/47/2/122/294788




  Introduction Top


The management of the airway in patients with postburn contracture over the neck and chest is often a challenge to anesthetists and otolaryngologists. Limited mouth opening and restricted neck movement due to scar contracture lead to a difficult airway.[1] In postburn contracture, the airway becomes difficult due to several causes such as limited mouth opening by cicatrized angles of the mouth, reduced oropharyngeal space, fixed flexion deformity at the neck, limited atlanto-occipital joint extension, lower submandibular space compliance, and altered tracheal position. The fixed flexion deformity of the neck leads to misalignment of the oral, pharyngeal, and laryngeal planes for oral or nasotracheal intubation. Tracheal intubation with help of direct laryngoscopy often leads to failed intubation due to the obstructed view of the larynx. Hence, video-assisted bronchoscopy is a useful adjunct for facilitating the tracheal intubation. Awake fiberoptic intubation (fiberoptic bronchoscope [FOB]) is an accepted choice for managing the anticipated difficult airway.[2] However, FOB intubation is often challenging for beginners but continuous practice is helpful to become skillful.[3] Awake intubation under the assistance of fiberoptic bronchoscopy with the help of guidewire is one of the best options in postburn contracture.[4] Here, we describe a case of difficult airway in a 12-year-old girl due to postburn contracture over the face, neck, and chest.


  Case Report Top


A 12-year-old girl presented with a history of acid burns 6 months ago that evolved into extensive contractures of the face, neck, chest, and upper extremity [Figure 1]. This distorted the front of the neck anatomy virtually obliterating the delineation of tissue or neck structures. She was scheduled for the release of the fibrotic burn contracture of the neck under general anesthesia. On examination, her vital signs were stable. The contractures were seen in the face, neck, chest, and upper limbs. The mouth opening of the patient was limited, and interincisor distance was <3 cm. She had severe fibrosis at the anterior part of the neck. Mallampati examination could not be done due to reduced mouth opening and flexed neck. She had a flexed flexion deformity of the neck. The distance between sternomental and thyromental area could not be evaluated because of extensive contracture at the anterior part of the neck. Extension and flexion of the neck were restricted.
Figure 1: Patient showing severe contracture at the neck and chest

Click here to view


Informed consent was obtained from parents of the patient before planning for the treatment. No premedication was given to the patient on the day of the surgical procedure. Before administering sedation, oxygen therapy at a rate of 6 L/min was commenced using a nasal cannula. After obtaining peripheral venous access, intravenous fentanyl and midazolam was titrated to achieve sedation to ensure compliance for the fiberoptic intubation. At first, 50 μg of fentanyl was given to this 24 kg child for two times (total 2.2–2.3 μg/kg) at intervals of approximately 2 min. All the monitoring machines are placed along with electrocardiography, oxygen saturation of arterial blood, and noninvasive blood pressure cuff. Baseline arterial pressure, respiratory rate, heart rate, and O2 saturation were 112/78 mmHg, 20/min, 90 beats/min, and 98%, respectively. After starting 6 L/min of oxygen through a nasal cannula, 0.5 mg of midazolam was administered 1–4 times (total 0.02–0.05 mg/kg) at a 2-min interval on the basis of hemodynamic, bispectral index, and observer assessment of alertness/sedation scale score. Topical lidocaine (2%) was sprayed into the oropharynx and larynx with the help of the laryngoscope. After topical lidocaine spray and adequate sedation with anxiolysis, video-guided fiberoptic bronchoscopy (Ambu ® aScope™, Copenhagen, Denmark) was done with a 7 mm size endotracheal tube (internal diameter) mounted on it. It was introduced through the nasal route and down to the larynx and trachea. The Ambu ® aScope™ [Figure 2] is a flexible scope designed for the patient with difficult airway. The anesthesia was subsequently maintained by N2O oxygen-sevoflurane with incremental doses of atracurium injection. Intravenously, fentanyl (100 μg) was given to provide intraoperative analgesia. The lungs were ventilated mechanically for achieving normocarbia. The intraoperative period was uneventful and safely extubated. After extubation, the patient was awake and breathing spontaneously. She was stable after extubation and shifted to the ward after monitoring for 2 h in the recovery room. Her further hospital stay was uneventful, and she was discharged after 7 days.
Figure 2: Ambu® aScope™ was used for intubation in difficult airway

Click here to view



  Discussion Top


Difficult airway is often a challenging situation to a clinician and causes anesthesia-related morbidity and mortality.[5] Patients of postburn contracture in the face and neck pose a unique clinical condition where difficult airway is always anticipated during orotracheal or nasotracheal intubation. Postburn contracture of the face and neck causes anatomical distortion which reduces the mouth opening and alters oropharyngeal airway. There are two pathological phases in burn injury, such as early phase and late phase. Each phase of burn has separate pathological characteristics. The patient with late phase of burn usually presents with contractures. In case of neck contracture, the main challenge is to control the airway during any general anesthesia. Otolaryngologists and anesthetists should work together during airway intervention. The basic principle for managing difficult airway includes proper assessment of the airway, availability of the materials and human resources, controlling airway by intubation, monitoring, and postoperative care of the airway.

In postburn contracture of the neck, the patient sometimes presents with distortion of the pharyngeal and laryngeal airway to upper airway stenosis. In burn injury, factors causing upper airway or tracheal stenosis include thermal burn or chemical irritation by inhaled smoke whereas mechanical injury can cause laryngotracheal stenosis by trauma with endotracheal tube cuff or tip. In this situation, the patient may require tracheostomy.[6] There are limited options for managing difficult airway. Awake fiberoptic intubation is always considered as the most prudent approach and called as the gold standard in patients by anticipating difficult airway.[7] Awake intubation is a painful and stimulation procedure and needs patient cooperation. Hence, we considered conscious sedation and anxiolysis before awake Ambu ® aScope™-guided nasotracheal intubation. Achieving topical anesthesia in patients with difficult airway is a challenging task because of anatomical abnormalities.[8] Moreover, using FOB in difficult airway for intubation needs expertise and longer learning curve.

Intubation with standard laryngoscope is not possible in postburn contracture of the neck and chest due to nonalignment of the oral cavity/pharynx/laryngeal axis by fixed flexion deformity. The best option for such airway management is awake intubation by fiberoptic bronchoscopy,[9] supraglottic devices, neck scar release before induction under local anesthesia or ketamine, and elective tracheostomy.[9],[10] Awake intubation is one of the safest options in patients with difficult airway.[11] Ambu ® aScope™ is a flexible scope which is used for intubation in difficult airway as done in our case. In this scope, a 6.5˝reusable liquid crystal display is usually used for video signal from the Ambu ® aScope™. The supraglottic airway device like laryngeal mask airway is very helpful as it not only establishes the safe airway but also maintains adequate ventilation, especially when we fail to achieve an adequate seal during attempted face mask ventilation.[9] Endotracheal intubation with the help of video-assisted fiberoptic laryngoscopy is a useful technique in patient of difficult airway.[12] It facilitates tracheal intubation with postburn contracture of the neck. Direct laryngoscopy is usually not successful as laryngeal view cannot be obtained, whereas videolaryngoscopy often overcomes this obstacle. However, certain difficulties may be seen during advancing the endotracheal tube toward the larynx through video monitor. This disadvantage can be corrected using fiberoptic bronchoscopy along with the use of guidewire under videolaryngoscopy.[13] Postburn contracture over the neck and chest with fixed flexed deformity is often challenging to the anesthetist.[14] In our case, because of the limited mouth opening, awake nasal intubation was done with the help of fiberoptic bronchoscopy. Oral fiberoptic intubation is often difficult technically in comparison to the nasal route since orotracheal intubation attempt tends to drift the endotracheal tube posteriorly abutting against the arytenoid cartilages at the larynx. There are a variety of airways available for intubation in oral route which helps to give clear visual pathway from the mouth to the pharynx and larynx and also preventing biting the fiberoptic scope with patent airway. Awake fiberoptic intubation is helpful under videolaryngoscopy guidance for the release of neck contractures under local anesthesia with severe mentosternal contracture.

Tracheostomy is not suitable in this case as fibrosed structures of the neck alter the anatomical landmark.[15],[16] Bullard laryngoscope is another option for intubation in the difficult airway, but it is expensive and difficult to operate. In case of limited mouth opening, it has been proven that the Bullard laryngoscope is extremely helpful.[17] Intraoperative planning and teamwork are required for positive outcomes to manage such difficult airway. For intubating the difficult airway like postburn contracture of the neck, face, and chest, difficult intubation kit such as FOB is a mandatory requirement as part of difficult airway trolley/kit to ensure timely and efficient control/securing airway during the perioperative period.


  Conclusion Top


Management of the airway in postburn contracture includes meticulous preoperative planning, patient preparation, skilled assistance, airway anesthesia, expertise, and gentle handling of the difficult airway. Airway expert should be alert during induction, maintenance, and extubation for safety of the patient. Proper planning with expert personnel reduces anesthesia-related morbidity and mortality in case postburn contracture of the neck with a difficult airway. Every patient of postburn contracture with difficult airway is considered as a unique, and the airway management plan should be individualized. Video FOB (Ambu ® aScope™) is better than a conventional laryngoscope for uneventful intubation in the difficult airway such as postburn contracture of the neck.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gupta P, Talwar V, Verma S. Modified mouth prop for orotracheal fibreoptic intubation. J Anaesthesiol Clin Pharmacol 2006;22:65-8.  Back to cited text no. 1
  [Full text]  
2.
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. 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;118:251-70.  Back to cited text no. 2
    
3.
Fitzgerald E, Hodzovic I, Smith AF. From darkness into light: Time to make awake intubation with video laryngoscopy the primary technique for an anticipated difficult airway? Anaesthesia 2015;70:387-92.  Back to cited text no. 3
    
4.
Saunders TG, Gibbins ML, Seller CA, Kelly FE, Cook TM. Videolaryngoscope-assisted flexible intubation tracheal tube exchange in a patient with a difficult airway. Anaesth Rep 2019;7:22-5.  Back to cited text no. 4
    
5.
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. 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;118:251-70.  Back to cited text no. 5
    
6.
Cakir K, Kilicarslan G, Bedirli N, Isik B. Anesthetic Management of Patients Who Expected to Have Difficult Air Way due to Post Burn Contractures. Gazi Med J 2018;29:231-3.  Back to cited text no. 6
    
7.
Ali QE, Siddiqui OA, Amir SH, Ahmad S, Jamil S. King vision video laryngoscope for severe post burn contracture neck: An encouraging experience. Rev Bras Anestesiol 2017;67:641-3.  Back to cited text no. 7
    
8.
Kandasamy R, Sivalingam P. Use of sevoflurane in difficult air-ways. Acta Anaesthesiol Scand 2000;44:627-9.  Back to cited text no. 8
    
9.
Divatia JV, Upadhye SM, Sareen R. Fiberoptic intubation in cicatricial membranes of the pharynx. Anaesthesia 1992;47:486-9.  Back to cited text no. 9
    
10.
Črnjar K, Kralik S, Kerovec Sorić I, Bekavac I, Barčot Z, Butković D. Difficult airway management–an old challenge: a case report. Paediatria Croatica 2019;63:38-41.  Back to cited text no. 10
    
11.
American Society of Anesthesiologists Task Force on Management of the Difficult Airway. 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 2003;98:1269-77.  Back to cited text no. 11
    
12.
Asai T, Shingu K. Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: Incidence, causes and solutions. Br J Anaesth 2004;92:870-81.  Back to cited text no. 12
    
13.
Park CD, Lee HK, Yim JY, Kang IH. Anesthetic management for a patient with severe mentosternal contracture: Difficult airway and scarce venous access – A case report. Korean J Anesthesiol 2013;64:61-4.  Back to cited text no. 13
    
14.
Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology 1996;84:686-99.  Back to cited text no. 14
    
15.
Sahajanandhan R, Saravanan PA, Ponniah M, Jacob JI, Gupta AK, Nambi GI. Post burn contracture neck with extreme microstomia and fibrosed obliterated nose-a unique airway challenge! J Anaesth Clin Pharmacol 2010;26:267-9.  Back to cited text no. 15
    
16.
Swain SK, Behera IC, Sahu MC. Bedside open tracheostomy at intensive care unit-our experiences of 1000 cases at a tertiary care teaching hospital of eastern India. Egypt J Ear Nose Throat Allied Sci 2017;18:49-53.  Back to cited text no. 16
    
17.
Ma´rquez XG, Ma´rquez AE. The bullard laryngoscope as an alternative in difficult airway management. A review. Diffic Airway 2002;3:8-14.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed99    
    Printed6    
    Emailed0    
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal