Procedural Challenges During Intubation in Patients With Oropharyngeal Masses: A Prospective Observational Study

The effect of free flap surgery for oral cancer on laryngeal grade and intubation difficulty

OBJECTIVE

The purpose of this study was to evaluate the change in laryngeal grade and intubation difficulty at subsequent surgery in patients with prior free flap reconstruction for oral cancer.

STUDY DESIGN

This retrospective case series included patients with a diagnosis of oral cancer who underwent free flap reconstruction (FFR) (S1) followed by a subsequent surgery (S2) which required intubation. The primary predictor variable was FFR. The primary outcome variable was the change in laryngeal grade, based on the classification of Cormack and Lehane, after FFR. Secondary outcomes were intubation difficulty and number of intubation attempts.

RESULTS

Thirty-three patients were included in the study. At S1, the average laryngeal grade was 1.1. There were 5 difficult intubations. The average time to S2 was 19 months. At S2, average laryngeal grade was 1.4. There were 17 difficult intubations. Analysis showed a significant association between FFR and a more obstructed view of the glottis at S2 (P = .007; 95% CI 0.101-0.808). FFR increased the odds of having >1 intubation attempt nearly 7-fold (OR 6.74; 95% CI 1.35-33.75), and the odds of a difficult intubation nearly 6-fold (OR 5.95; 95% CI 1.84-19.19) at S2, both of which were significant (P = .011 and P = .002, respectively) CONCLUSIONS: This investigation found an association between FFR for patients with oral cancer and a higher laryngeal grade - that is, a more obstructed view of the glottis - at subsequent surgery, in addition to increased intubation difficulty and greater number of intubation attempts.

Nasendoscopy to Predict Difficult Videolaryngoscopy: A Multivariable Model Development Study

BACKGROUND

Transnasal videoendoscopy (TVE) is the standard of care when staging pharyngolaryngeal lesions. This prospective study determined if preoperative TVE improves the prediction of difficult videolaryngoscopic intubation in adults with expected difficult airway management in addition to the Simplified Airway Risk Index (SARI).

METHODS

374 anesthetics were included (252 with preoperative TVE). The primary outcome was a difficult airway alert issued by the anesthetist after Macintosh videolaryngoscopy. SARI, clinical factors (dysphagia, dysphonia, cough, stridor, sex, age and height) and TVE findings were used to fit three multivariable mixed logistic regression models; least absolute shrinkage and selection operator (LASSO) regression was used to select co-variables.

RESULTS

SARI predicted the primary outcome (odds ratio [OR] 1.33; 95% confidence interval [CI] 1.13-1.58). The Akaike information criterion for SARI (327.1) improved when TVE parameters were added (311.0). The Likelihood ratio test for SARI plus TVE parameters was better than for SARI plus clinical factors (p < 0.001). Vestibular fold lesions (OR 1.82; 95% CI 0.40-8.29), epiglottic lesions (OR 3.37; 0.73-15.54), pharyngeal secretion retention (OR 3.01; 1.05-8.63), restricted view on rima glottidis <50% (OR 2.13; 0.51-8.89) and ≥50% (OR 2.52; 0.44-14.56) were concerning.

CONCLUSION

TVE improved prediction of difficult videolaryngoscopy in addition to traditional bedside airway examinations.

A Prospective Observational Study of Video Laryngoscopy Use in Difficult Airway Management

OBJECTIVES/HYPOTHESIS

Video laryngoscopy has grown tremendously in popularity over the last decade for management of the anticipated difficult airway. The use of video laryngoscopy has not been adequately studied in the head and neck pathology patient population, including those with masses, previous head and neck surgery, or radiation.

STUDY DESIGN

Prospective observational study.

METHODS

This study included 100 patients with head and neck pathology undergoing awake flexible bronchoscopic intubation for nonemergency surgery requiring general anesthesia. After the performance of awake flexible bronchoscopic intubation and induction of anesthesia, video laryngoscopy was performed with the CMAC D blade and Glidescope AVL. The primary outcome was the modified Cormack-Lehane view obtained on video laryngoscopy.

RESULTS

One hundred patients were enrolled in the study. After exclusions, 92 patients underwent video laryngoscopy with both the CMAC D blade and the Glidescope AVL. Thirty-seven patients (40.2%) had a Cormack-Lehane view ≥3 with the CMAC D blade, and 28 patients (30.4%) had a Cormack-Lehane view ≥3 with the Glidescope AVL. There were no complications from awake flexible bronchoscopic intubation or video laryngoscopy.

CONCLUSIONS

There is a high incidence of inability to obtain a view of the glottis with video laryngoscopy in patients with head and neck pathology, particularly airway masses.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:82-86, 2021.