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“A” mystery of difficult intubation
American Journal of Emergency Medicine (2009) 27, 368.e3–368.e4
www.elsevier.com/locate/ajem
Case Report “A” mystery of difficult intubation Abstract Glottic web may be congenital or a result from injury of endotracheal intubation, thermal, corrosive, and endoscopic surgery. We report a case of difficult intubation and a glottic web was revealed from bronchoscopic examination after extubation. Treatment options include laser web lysis, kneel placement, or open surgery. Glottic web, though rare, may be a reason for difficult endotracheal intubation. Glottic web, though rare, may be a reason for difficult intubation. A 52-year-old obese woman with a history of diabetes and sleep apnea presented with acute hypercapnic respiratory failure necessitating an endotracheal intubation. Resistance was felt while trying to insert an endotracheal tube by an experienced physician. He has to choose an endotracheal tube with a much smaller inner diameter (6.5 mm) to pass through the vocal cord.
The patient passed a spontaneous breath trial 5 days later but with a negative cuff leak test. Bronchoscopy was arranged for evaluation of the vocal cords and to guide the extubation. A whitish bandlike tissue bridging the middle part of vocal cords was noted, forming an alphabet “A” (Fig. 1) with the endotracheal tube passing through the posterior lumen. No stridor or respiratory distress was noted while the endotracheal tube and bronchoscope were withdrawn above the vocal cords for 5 minutes. She was then extubated. She has been intubated twice before these episodes, both for hypercapnic respiratory failure, at 9 months and 2 years ago, respectively. She has hoarseness but no stridor after her second intubation. This glottic web might be congenital or a result from her previous intubations. She declined further management of the glottic web and was discharged. Glottic web may be congenital [1] or a result from injury of endotracheal intubation, thermal, corrosive, and endoscopic surgery [2]. Treatment includes laser web lysis [2], kneel placement, or open surgery [3]. Glottic web, though rare, may be a reason for difficult intubation. The diagnosis could be made with a bronchoscopic or laryngoscopic examination after extubation. Wei-Khie Kuar MD Department of Intensive Care Medicine Chi-Mei Medical Center Tainan, Taiwan Wen-Liang Yu MD Department of Intensive Care Medicine Chi-Mei Medical Center Tainan, Taiwan Department of Internal Medicine Taipei Medical University Taipei, Taiwan Shian-Chin Ko MD Department of Pulmonary Medicine Chi-Mei Medical Center Tainan, Taiwan
Fig. 1 Bronchoscopy showed whitish bandlike tissue bridging the middle part of vocal cords, forming an alphabet “A.” 0735-6757/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
Che-Kim Tan MD Department of Intensive Care Medicine Chi-Mei Medical Center Tainan, Taiwan
368.e4
Case Report Department of Internal Medicine Taipei Medical University Taipei, Taiwan E-mail address: [email protected]
doi:10.1016/j.ajem.2008.07.002
References [1] Cohen SR. Congenital glottic webs in children. A retrospective review of 51 patients. Ann Otol Rhinol Laryngol Suppl 1985;121:2-16. [2] Gallivan GJ. Bilateral vocal fold posterior glottic/subglottic stenotic web resected with contact tip Nd-YAG laser. J Voice 2002;16:415-21. [3] Edwards J, Tanna N, Bielamowicz SA. Endoscopic lysis of anterior glottic webs and silicone keel placement. Ann Otol Rhinol Laryngol 2007;116:211-6.
www.elsevier.com/locate/ajem
Case Report “A” mystery of difficult intubation Abstract Glottic web may be congenital or a result from injury of endotracheal intubation, thermal, corrosive, and endoscopic surgery. We report a case of difficult intubation and a glottic web was revealed from bronchoscopic examination after extubation. Treatment options include laser web lysis, kneel placement, or open surgery. Glottic web, though rare, may be a reason for difficult endotracheal intubation. Glottic web, though rare, may be a reason for difficult intubation. A 52-year-old obese woman with a history of diabetes and sleep apnea presented with acute hypercapnic respiratory failure necessitating an endotracheal intubation. Resistance was felt while trying to insert an endotracheal tube by an experienced physician. He has to choose an endotracheal tube with a much smaller inner diameter (6.5 mm) to pass through the vocal cord.
The patient passed a spontaneous breath trial 5 days later but with a negative cuff leak test. Bronchoscopy was arranged for evaluation of the vocal cords and to guide the extubation. A whitish bandlike tissue bridging the middle part of vocal cords was noted, forming an alphabet “A” (Fig. 1) with the endotracheal tube passing through the posterior lumen. No stridor or respiratory distress was noted while the endotracheal tube and bronchoscope were withdrawn above the vocal cords for 5 minutes. She was then extubated. She has been intubated twice before these episodes, both for hypercapnic respiratory failure, at 9 months and 2 years ago, respectively. She has hoarseness but no stridor after her second intubation. This glottic web might be congenital or a result from her previous intubations. She declined further management of the glottic web and was discharged. Glottic web may be congenital [1] or a result from injury of endotracheal intubation, thermal, corrosive, and endoscopic surgery [2]. Treatment includes laser web lysis [2], kneel placement, or open surgery [3]. Glottic web, though rare, may be a reason for difficult intubation. The diagnosis could be made with a bronchoscopic or laryngoscopic examination after extubation. Wei-Khie Kuar MD Department of Intensive Care Medicine Chi-Mei Medical Center Tainan, Taiwan Wen-Liang Yu MD Department of Intensive Care Medicine Chi-Mei Medical Center Tainan, Taiwan Department of Internal Medicine Taipei Medical University Taipei, Taiwan Shian-Chin Ko MD Department of Pulmonary Medicine Chi-Mei Medical Center Tainan, Taiwan
Fig. 1 Bronchoscopy showed whitish bandlike tissue bridging the middle part of vocal cords, forming an alphabet “A.” 0735-6757/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
Che-Kim Tan MD Department of Intensive Care Medicine Chi-Mei Medical Center Tainan, Taiwan
368.e4
Case Report Department of Internal Medicine Taipei Medical University Taipei, Taiwan E-mail address: [email protected]
doi:10.1016/j.ajem.2008.07.002
References [1] Cohen SR. Congenital glottic webs in children. A retrospective review of 51 patients. Ann Otol Rhinol Laryngol Suppl 1985;121:2-16. [2] Gallivan GJ. Bilateral vocal fold posterior glottic/subglottic stenotic web resected with contact tip Nd-YAG laser. J Voice 2002;16:415-21. [3] Edwards J, Tanna N, Bielamowicz SA. Endoscopic lysis of anterior glottic webs and silicone keel placement. Ann Otol Rhinol Laryngol 2007;116:211-6.