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Table of Contents
LETTER TO EDITOR
Year : 2014  |  Volume : 30  |  Issue : 4  |  Page : 586-587

Is computed tomography scan the ultimate modality for airway evaluation?


1 Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication14-Oct-2014

Correspondence Address:
Dalim Kumar Baidya
Department of Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.142894

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How to cite this article:
Maitra S, Krishnan G, Baidya DK, Chumber S. Is computed tomography scan the ultimate modality for airway evaluation? . J Anaesthesiol Clin Pharmacol 2014;30:586-7

How to cite this URL:
Maitra S, Krishnan G, Baidya DK, Chumber S. Is computed tomography scan the ultimate modality for airway evaluation? . J Anaesthesiol Clin Pharmacol [serial online] 2014 [cited 2020 Jul 7];30:586-7. Available from: http://www.joacp.org/text.asp?2014/30/4/586/142894

Sir,

Patients with anterior mediastinal mass pose special anesthetics challenges, and they are prone to perioperative complications particularly from airway collapse. [1] We present anesthetic challenges in a 78-year-old patient suffering from a retrosternal goiter and thymic cyst presented with compressive symptoms.

Written informed consent was obtained for publication of this case. A 78-year-old man was admitted to our hospital with the complaints of cough and expectoration for 5 months. He also complained of inability to lie down in left lateral posture but did not have any difficulty in the supine position even during sleep. There was also no history of respiratory distress and stridor neither at rest nor with activity.

Computed tomography (CT) scan of neck and thorax revealed a thyroid swelling extending from the neck into the superior mediastinum along with a thymic cyst. Both CT scan [Figure 1] and a chest X-ray found a deviation of the trachea, and moderate compression of thoracic trachea, with a compression of the laryngeal vestibule and cervical trachea was noted [Figure 1]. The minimum internal diameter of the thoracic trachea was found to be 6.0-7.0 mm. All other investigations were within normal limit.{Figure 1}

General anesthesia with endotracheal (ET) intubation along with thoracic epidural catheter for postoperative pain management was planned. Awake fiberoptic bronchoscope guided intubation with airway block, and topical anesthesia was planned. To anesthetize upper airway, 5 ml of 4% lignocaine nebulization was done for 10 min, followed by 2 ml 4% lignocaine injected into the trachea. We used real-time ultrasound to identify trachea as it was deviated.

In the operating room, after attaching all the monitors, fiberoptic bronchoscopy was attempted through oral route using an oral bite block. We noted a near total compression of the trachea started just below the vocal cord extending up to just above the carina. It was on the contrary to the preoperative CT scan finding. However, we were able to introduce the fiberscope in the trachea and a 7.0 mm ID cuffed flexo-metallic ET tube was rail-roaded over the scope. The tip of the ET tube was kept just above the carina passing the distal end of tracheal compression. The fiberscope was taken out under vision, and anesthesia was induced with 250 mg intravenous thiopentone sodium and after confirmation of bilateral air entry, 25 mg atracurium was given.

At the end of the surgery, elective postoperative ventilation was planned. After, a check fiberoptic bronchoscopy, we exchanged the flexo-metallic ET tube with an 8.0 mm ID cuffed ET tube over an airway exchange catheter. On the next day, he was extubated uneventfully in the surgical intensive care unit.

Computed tomography scan is one of the most commonly used diagnostic modality for this purpose. CT scan predicts perioperative complications in these patients. [2],[3]

In our case, CT scan correctly delineated compression of the larynx and cervical trachea, but failed to detect a significant thoracic tracheal compression. As CT scan provides only static image, [4] fiberoptic bronchoscopy does have a role in such patients because it provided dynamic imaging. [5] As magnetic resonance imaging (MRI) provides excellent soft tissue contrast, [6] so it is an important preoperative investigation for tumors of the mediastinum. [7],[8] We suggest a preoperative MRI for proper anesthetic planning in such patients.

 
  References Top

1.
Gardner JC, Royster RL. Airway collapse with an anterior mediastinal mass despite spontaneous ventilation in an adult. Anesth Analg 2011;113:239-42.  Back to cited text no. 1
    
2.
Béchard P, Létourneau L, Lacasse Y, Côté D, Bussières JS. Perioperative cardiorespiratory complications in adults with mediastinal mass: Incidence and risk factors. Anesthesiology 2004;100:826-34.  Back to cited text no. 2
    
3.
Blank RS, de Souza DG. Anesthetic management of patients with an anterior mediastinal mass: Continuing professional development. Can J Anaesth 2011;58:853-9, 860.  Back to cited text no. 3
    
4.
Udayakumar P, Srikanti M, Vijayakumar V, Kandappan G. Role of newer imaging modalities for airway assessment in dynamic tracheal compression. J Anaesthesiol Clin Pharmacol 2014;30:101-3.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Sen S, Chhabra A, Ganguly A, Baidya DK. Esophageal polyp as a posterior mediastinal mass: Intraoperative dynamic airway obstruction requiring emergency tracheostomy. J Anaesthesiol Clin Pharmacol 2014;30:97-100.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Puderbach M, Hintze C, Ley S, Eichinger M, Kauczor HU, Biederer J. MR imaging of the chest: a practical approach at 1.5T. Eur J Radiol 2007;64:345-55.  Back to cited text no. 6
    
7.
Juanpere S, Cañete N, Ortuño P, Martínez S, Sanchez G, Bernado L. A diagnostic approach to the mediastinal masses. Insights Imaging 2013;4:29-52.  Back to cited text no. 7
    
8.
Narang S, Harte BH, Body SC. Anesthesia for patients with a mediastinal mass. Anesthesiol Clin North America 2001;19:559-79.  Back to cited text no. 8
    




 

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