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CASE SERIES
Year : 2020  |  Volume : 13  |  Issue : 5  |  Page : 557-559  

An innovative approach to the intubation of cervical lipomas: Taking the easy way in!


Department of Anaesthesiology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India

Date of Submission10-Jun-2019
Date of Decision26-Aug-2019
Date of Acceptance15-Oct-2019
Date of Web Publication7-Sep-2020

Correspondence Address:
Gauri Raman Gangakhedkar
13/14, Chandangad Apartments, Next to Rahul Nagar, Near Karve Putala, Kothrud, Pune - 411 038, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_165_19

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  Abstract 


The use of videolaryngoscopes for difficult intubation as an adjunct has been established in the various international airway guidelines. However, planning a case of difficult intubation mandates the use of proper positioning in order that the intubation is successful and atraumatic. Various methods to facilitate proper positioning have been described that include the use of bolsters, preformed pillows, and ramps. The trials faced by anesthetists who attempt to successfully negotiate the difficult airway posed by cervical lipomas consist of difficulty faced during positioning for intubation, need for additional need for workforce during positioning, and the need to transfer an intubated, anesthetized patient for surgery while facing the risk of accidental disconnection and extubation. This case series describes an innovative method of positioning to assist intubation that requires no additional equipment, reduces the chances of accidents during positioning, and in conjunction with the use of videolaryngoscope simplifies a difficult airway procedure.

Keywords: Cervical lipoma, difficult airway, intubation, videolaryngoscope


How to cite this article:
Gangakhedkar GR, Poduval D, Narkhede HH, Buddhi M, Patel RD. An innovative approach to the intubation of cervical lipomas: Taking the easy way in!. Med J DY Patil Vidyapeeth 2020;13:557-9

How to cite this URL:
Gangakhedkar GR, Poduval D, Narkhede HH, Buddhi M, Patel RD. An innovative approach to the intubation of cervical lipomas: Taking the easy way in!. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Oct 22];13:557-9. Available from: https://www.mjdrdypv.org/text.asp?2020/13/5/557/294341




  Introduction Top


Cervical lipomas restrict neck extension and are markers of difficult intubation. While there are reports in the literature of use of cervical epidural or local anesthesia for excision, giant lipomas (size >10 cm)[1],[2] [Figure 1] by and large necessitate the use of general anesthesia. The use of videolaryngoscopes to reduce the neck extension required to align the axes for intubation is an established strategy when facing a difficult airway. Such intubations prove to be a challenge on account of the need to intubate either in lateral position or on a separate trolley, followed by instituting the prone position after induction. Here, we present a series of cases where an innovative technique of optimizing intubation allowed us to minimize the number of resources required for positioning and intubate with ease.
Figure 1: Location of cervical lipomas

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  Case Reports Top


Case 1

A 35-year-old male (height = 164 cm, weight = 74 kg, and body mass index [BMI] = 27.61 kg/m2) presented for surgical excision of a giant pedunculated cervical lipoma (16 cm × 12 cm). With MPC Class II and possible subluxation of mandible of +1, the patient had no neck extension (90°). Difficult intubation was anticipated and explained. We use a Maquet operating table consisting of a combination of head, chest abdomen, and leg plates which are covered with detachable mattresses. The mattress at the headend was detached and repositioned to allow the lipoma to fall freely into the newly created space. This is the proposed “R.D. technique”[Figure 2]. The patient could now lie comfortably on the surgical table. After 3 min of preoxygenation, standard induction with intravenous fentanyl 100 μg, intravenous propofol 150 mg, and intravenous vecuronium was commenced. Using a size 3 AirTraq, a Cormack–Lehane (CL) Grade of IIa was achieved. Tracheal intubation was then performed with a 7.5-mm cuffed endotracheal tube. Oxygen, nitrous oxide (50/50), and sevoflurane at 1 minimum alveolar concentration were used for the maintenance. The patient was given left lateral position after the intubation. After an uneventful surgery, the patient was extubated on adequate return of tone, power, reflexes, and consciousness after thorough suctioning and reversal of neuromuscular blockade.
Figure 2: In clockwise manner, operating table (Maquet Alphastar), table with detached mattresses, patient position for intubation, intubation using an AirTraq laryngoscope

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Case 2

A 45-year-old male (BMI = 26 kg/m2) with a nonpedunculated cervical lipoma (12 cm × 8 cm) was induced using the R.D. technique of positioning. With the AirTraq size 3, a CL grade IIb was achieved; however, intubation had to be done using a bougie as a guide. He underwent an uneventful surgery in the prone position.

Case 3

A 54-year-old male (BMI = 29 kg/m2) with a pedunculated cervical lipoma (6 cm × 8 cm) underwent surgery after intubation using the R.D.'s technique. A CL Grade I was achieved with Airtraq size 3. Prone position was used for the surgery.

Case 4

A 39-year-old male (BMI = 26 kg/m2) underwent successful surgical excision of a nonpedunculated cervical lipoma (10 cm × 8 cm) after intubation using the R.D.'s technique in the prone position, after obtaining CL Grade I with Airtraq size 3.

Case 5

A 65-year-old male (BMI = 30 kg/m2) underwent pedunculated cervical lipoma excision in the lateral position after a bougie-guided intubation using the R.D.'s technique of positioning for intubation with AirTraq size 3, where a CL Grade of III was obtained on laryngoscopy.


  Discussion Top


Surgical excision of cervical lipomas under general anesthesia presents complex airway management challenge. The restricted neck extension due to location of the lesion leads to difficulty in the alignment of neck axes and in turn affecting the laryngoscopic view.[3],[4] The availability of videolaryngoscopes, AirTraq in particular, with its channeled blade (20 cm in length and 14-mm width) and angulated vision (93°) proves to be a valuable resource when the laryngoscopy would otherwise be challenging.[5]

Awake fiber-optic intubation remains a gold standard in cases of anticipated difficult intubation but requires training, technical expertise, has a long learning curve, and requires an extremely cooperative patient.[4] Videolaryngoscopy using AirTraq presents an easier alternative. A study by Alzeftawy concurred with the same, where they found that the time required for intubation using an AirTraq was significantly lesser than that required by fiberoptic bronchoscope.[6] We propose that using AirTraq in conjunction with R.D. technique would prove to be even more advantageous.

Classical intubation techniques for patients with cervical lipomas involve induction on a trolley with use of bolsters to allow optimal airway positioning while accommodating lipoma. This necessitates either physically transferring an intubated patient onto the operating table or turning the patient from supine to prone while on the operating table, increasing the chances of accidental extubation, disconnection, and other mishaps.[7] The other alternative is to intubate in the lateral position. While there is evidence to prove that the lateral position, left in particular, might aid intubation by keeping the airway patent and moving the tongue out of the field of vision; the speed and comfort of intubation remain the highest when performed in the supine position.[8]

While a recent review suggests that supraglottic airway devices are a popular choice for anesthesia in the prone position, current evidence is mostly from retrospective studies and case reports. It is thus insufficient to consider them as safe replacements for endotracheal tubes.[9]

The “R.D. technique” reduces the need for additional equipment during positioning the patient. The modification allows the swelling to fall into the newly formed cavity and for patient position during intubation to resemble the one used in routine practice, thus adding to ease of intubation. The potential limitations include the incongruousness between the variability in the size of the mass and constancy of space created by the modification and the possibility of damage to the mass. While it could be argued that larger masses may not fit in the space generated from the modification, it remains feasible since the adipose tissue gets easily compressed to fit into the new mold. The concern regarding injury to the mass becomes moot in lipomas as they generally present as smooth skin covered masses and rarely ulcerate.


  Conclusion Top


By a simple yet an effective modification of the operating table using the R.D. technique in conjunction with the use of a videolaryngoscope, the challenge of the difficult intubation in cervical lipoma can be overcome with greater ease. This technique has potential applications in other similar surgeries.

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.
Alshadwi A, Nadershah M, Salama A, Bayoumi A. Giant deep neck lipoma: A case report and review of the literature. Clin Surg 2017;2:1299.  Back to cited text no. 1
    
2.
Singh RP, Shukla A, Verma S. Giant cervical lipoma excision under cervical epidural anesthesia: A viable alternative to general anesthesia. Anesth Essays Res 2011;5:204-6.  Back to cited text no. 2
  [Full text]  
3.
ReenaUse of Ambu® aScope™ 3 in difficult airway management in giant lipoma neck. Egypt J Anaesthesia 2016;33:121-3. [DOI: 10.1016/j.egja.2016.10.006].  Back to cited text no. 3
    
4.
Ali QE, Siddiqui OA, Amir SH, Azhar AZ, Ali K. Airtraq® optical laryngoscope for tracheal intubation in a patient with giant lipoma at the nape: A case report. Rev Bras Anestesiol 2012;62:736-40.  Back to cited text no. 4
    
5.
Dimitriou V, El Kouny A, Al Harbi M, Wambi F, Tawfeeq N, Tanweer A, et al. Airtraq8 optical laryngoscope for tracheal intubation in a patient with an uncommon giant lipoma on the posterior aspect of neck and additional risk factors of anticipated difficult airway: A case report. Middle East J Anaesthesiol 2015;23:355-8.  Back to cited text no. 5
    
6.
Alzeftawy AE, El-Daba AA. Awake orotracheal intubation using fiberoptic bronchoscope versus Airtraq laryngoscope in morbidly obese patients. Ain Shams J Anaesthesiol 2017;10:177-81.  Back to cited text no. 6
    
7.
Feix B, Sturgess J. Anaesthesia in the prone position. Continuing Educ Anaesthesia Crit Care Pain 2014;14:291-7.  Back to cited text no. 7
    
8.
McCaul CL, Harney D, Ryan M, Moran C, Kavanagh BP, Boylan JF, et al. Airway management in the lateral position: A randomized controlled trial. Anesth Analg 2005;101:1221-5.  Back to cited text no. 8
    
9.
Kubo Y, Kiyama S, Suzuki A, Kondo I, Uezono S. Use of supraglottic airway devices in the prone position. J Anesth Clin Res 2017;8:797.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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