Title: A case of laryngeal venous malformations requiring repeated
advanced airway management in the perioperative course.
Author list:
Fumi Maruyama, MD
e-mail:fumi-makino.mane@tmd.ac.jp
Department of Intensive Care Medicine, Tokyo Medical and Dental
University
Takahiro Masuda, MD
e-mail: tmasicu@tmd.ac.jp
Department of Intensive Care Medicine, Tokyo Medical and Dental
University
Nobuyuki Nosaka, MD, Ph.D.
e-mail: nnosaka.ccm@tmd.ac.jp
Department of Intensive Care Medicine, Tokyo Medical and Dental
University
Kenji Wakabayashi, MD, Ph.D.
e-mail: wakabayashi.ccm@tmd.ac.jp
Department of Intensive Care Medicine, Tokyo Medical and Dental
University
Corresponding author: Takahiro Masuda, MD
e-mail: tmasicu@tmd.ac.jp
Address: 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
Postal code: 113-8510
Tel: +81 – 3 – 5803 – 5959
Fax: +81 – 3 – 5803 – 5652
Abstract
Laryngeal venous malformations rarely but do cause airway obstruction
resulting in life-threatening events. The perioperative airway
management for the patients with them have not been well established. We
suggest a strategy for laryngeal venous malformations management in the
patients who undergo surgery in addition to planning for airway
management.
Key words; Difficult airway management, Laryngeal venous malformation,
Awake tracheal intubation
Manuscript
Introduction
Laryngeal venous malformations are the most common slow-flow vascular
malformations in the head and neck region. Laryngeal venous malformation
in the upper airway rarely but does cause airway obstruction or bleeding
resulting in life-threatening events [1,2], hence requires a prompt
diagnosis and treatment. Therapeutic strategy for venous malformations
includes sclerotherapy, surgery, or embolism, and the choice of strategy
depends on the stage and type of the lesions; however, specific criteria
for treating laryngeal venous malformations have not been well
established [3-5]. We herein report a perioperative case that
required repeated airway management due to laryngeal venous
malformations.
Case history
A 64-year-old man, who had a stable clinical course of laryngeal venous
malformations, underwent awake tracheal intubation under a bronchoscopy
guide for safety concerns over difficult airway to receive cervical
laminoplasty for the cervical disc herniation. The intraoperative
bronchoscopic examination found that two venous malformations existed in
the lower pharynx as if they sandwiched the left part of the arytenoid
cartilage, while the airway was sufficiently patent (Figure 1). The
intubation procedure was completed smoothly and successfully without any
complications. The surgical operation and anesthetic management under
total intravenous anesthesia with propofol and remifentanil were all
completed uneventfully. The surgery and anesthesia times were 1 h 40 min
and 4 h 20 min, respectively. Total blood loss amount and urine output
during the operation were 30 g and 320 mL, respectively. The total
amount of intraoperative fluid transfusion was 1,050 mL without any
blood transfusion. Soon after extubation, however, the patient
demonstrated obvious stridor on the operating table. The emergency
bronchoscopy found the swollen venous malformations that were enlarged
compared to the pre-operative exam and nearly obstructing the glottis
(Figure 2). Accordingly, the anesthesiologist immediately reintubated
him with an awake tracheal intubation procedure with a fiberscope, which
was smoothly performed. He was then admitted to the intensive care unit
(ICU) for postoperative care.
In the perioperative management, the patient received close examinations
by otolaryngologists in the ICU. On the postoperative day 1, the patient
was extubated after confirming the swollen but smaller venous
malformations with sufficient space in the airway by laryngoscope
examinations. He developed no respiratory symptoms such as stridor or
hoarseness after the extubation, and then received hydrocortisone 100 mg
q 8 hours as prophylaxis for laryngeal edema. The clinical course was
stable and uneventful during the day of extubation.
On the morning of postoperative day 2, however, when he sat up with a
help of two nurses for rehabilitation in the ICU, he had suddenly shown
the sign of suffocation and lost his consciousness with a sharp decrease
in the oxygen saturation (SpO2) below 80 %. The patient
was immediately reintubated with a channeled video laryngoscope where
re-swollen venous malformations were seen. The patient fully recovered
his consciousness after reintubation without any abnormalities in the
following head computed tomography, suggesting his loss of consciousness
was due to transient suffocation by the venous malformations. The
tracheostomy was placed on the postoperative day 5 and then transferred
to another hospital to receive sclerotherapy for the venous
malformations.
Discussion
This case report described the unstable nature of laryngeal venous
malformations which caused airway blockage in the postoperative period.
Despite repeated and careful laryngoscope examinations of the laryngeal
venous malformations, we could not avoid the suffocation event after the
cervical surgery. Several factors might have been associated with the
worsening edema of the laryngeal venous malformations; the surgical
intervention to the neck region itself; repeated endotracheal intubation
procedures that caused mechanical contact between the endotracheal tube
and venous malformations; changes in intrathoracic pressure caused by
mechanical ventilation that would affect blood pressure and venous
return; and the unusual fluid balance due to perioperative fluid
therapy.
Clinical guidelines for the treatment of laryngeal venous malformations
are not currently available, hence a preoperative assessment of risk of
difficult airway by specialists involving otolaryngologists,
orthopedics, anesthesiologists, and intensivists, is as important as
close perioperative monitoring in perioperative management. In
retrospect, preoperative interventions to the laryngeal venous
malformations including sclerotherapy or even tracheostomy might have
been a strategic option for this patient in order to secure the airway
during the perioperative management of the cervical operation under
general anesthesia.
Importantly, this case report also depicted the usefulness and safety of
awake intubation in emergent difficult airway management in the ICU
[6]. Urgent tracheal intubation in the ICU is frequently performed
with rapid sequence induction, which is associated with severe
complications such as cardiovascular instability, severe hypoxia, and
cardiac arrest at worst [7]. In this regard, awake intubation with a
video device such as a bronchoscopy or video laryngoscope has certain
merits and can be safely accomplished even in an emergency [8,9],
although some training and experience are required for developing the
skills. In this case, the awake intubation with a channeled video
laryngoscope while maintaining spontaneous breathing was done without
any complications. From a patient-safety viewpoint, acquisition of awake
intubation skills would be an important skill for all the physicians
working in emergency and perioperative care settings.
Conclusion
In this case report, there are three points from this case. Firstly,
laryngeal venous malformations can be a risk factor of airway
obstruction in perioperative management. Secondly, the interdisciplinary
assessment and discussion of the patients is important especially for
the head and neck surgery. Finally, the awake tracheal intubation can be
a helpful skill for such a critical care situation.