|Year : 2022 | Volume
| Issue : 2 | Page : 323-324
Difficult airway management in a case of bilateral congenital torticollis
C Priyanka, S Shanu, R Brindha
Department of Anesthesiology, Vinayaka Missions Kirupananda Variyar Medical College and Hospital, Salem, Tamil Nadu, India
|Date of Submission||09-May-2022|
|Date of Decision||14-May-2022|
|Date of Acceptance||17-May-2022|
|Date of Web Publication||09-Sep-2022|
Department of Anesthesiology, Vinayaka Missions Kirupananda Variyar Medical College and Hospital, VMRF (DU), Salem, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Anatomical disorders of the head and neck pose a serious challenge to an anesthesiologist in terms of difficult intubation. Securing airway requires a detailed preanesthesia evaluation to assess any issues associated with the disease, especially concerning the airway. This is the case of a 46-year-old male with congenital bilateral torticollis posted for elective functional endoscopic sinus surgery. A detailed preanesthetic checkup was done and was anticipated a difficult airway situation, hence planned for an awake intubation. We performed a successful awake fiber-optic intubation. Excessive muscular atrophy and fibrosis characterize congenital bilateral torticollis, resulting in sternocleidomastoid tension and limited cervical motion. During intubation, asymmetry in the face caused a mismatch between the facial and cervical midlines, making sniffing difficult. Successful anesthetic management in a case of congenital bilateral torticollis requires thorough knowledge about the anatomical changes and also the expertise in fiber-optic bronchoscopy.
Keywords: Awake intubation, difficult airway, fiber-optic bronchoscopy, torticollis
|How to cite this article:|
Priyanka C, Shanu S, Brindha R. Difficult airway management in a case of bilateral congenital torticollis. BLDE Univ J Health Sci 2022;7:323-4
Congenital torticollis, which is also called as the twisted neck or wry neck is a common musculoskeletal defect that appears at or shortly after birth. It manifests as lateral flexion of the head to the ipsilateral side with rotation to the contralateral side due to unilateral shortening and increased tone of the sternocleidomastoid. Fiber-optic intubation with fiber-optic bronchoscope is the main stay of difficult airway management in awake, sedated, and anesthetized patients. Awake fiber-optic intubation preserves the respiratory drive and maintains airway patency.
| Case Report|| |
A 46-year-old male presented with complaints of headache and bilateral nasal obstruction for 1 month. The patient had no comorbidities. No congenital or developmental anomalies. The patient was born through normal vaginal delivery. He was found to have bilateral torticollis since childhood. The patient had stable vitals. Systemic examination found to be normal. Airway examination as follows: mallampati grading 3, thyromental distance <6.5 cms, inter-incisor distance admits two fingers, upper lip bite test-Grade 2, sternomental distance – 10 cms, neck circumference – 41 cms, short neck, neck movements restricted, facial asymmetry noted, no dentures, no loose, or missing tooth. His height and weight are 169 cms and 69 kgs, respectively. Body mass index is 24.2. Machine and operation theater check done. Resuscitation and difficult airway cart kept ready by the side and the equipment for tracheostomy was made available. Fiber-optic bronchoscope kept standby. The patient was made to lie supine. Electrocardiogram, noninvasive blood pressure, SpO2, and end-tidal CO2 were applied. Premedicated with injection ondansetron 4 mg iv and injection glycopyrrolate 0.2 mg iv. Nasal decongestion was done with oxymetazoline drops in both the nostrils. Nebulized was done with 4% lignocaine (4 ml). Bilateral Superior laryngeal nerve block and transtracheal block given with injection lignocaine with adrenaline 3 ml each. Ten percent lignocaine spray-2 puffs given intra-orally to anesthetize posterior tongue, tonsillar pillars, and posterior pharynx. Supplemental oxygen was given at 4 l/min using nasal cannula.
Intubation attempted initially with video laryngoscope and obtained the glottic view Cormack–Lehane 4 not able to visualize the vocal cords. Our next attempt at intubation was with fiber-optic bronchoscope. Fiber-optic bronchoscope checked and 7.5 size flexometallic endotracheal tube prefixed. Fiber-optic bronchoscope introduced through the right nostril after few manipulations and was able to visualize the vocal cords. Injection lignocaine with adrenaline 2 ml sprayed onto the vocal cords with “spray as you go technique.” Fiber-optic bronchoscope passed till carina. Endotracheal tube pushed inside and fiber-optic bronchoscope removed. Bilateral air entry checked and tube fixed appropriately. Injection propofol 100 mg and injection vecuronium 7 mg given intravenously N2O:O2 at 3:2 with isoflurane 0.6%–1% used for maintenance along with vecuronium 1 mg when needed. Intraoperative uneventful injection dexamethasone 8 mg given intravenously to reduce airway edema. After regaining adequate airway reflexes, extubating was done.
| Discussion|| |
Excessive muscular atrophy and fibrosis characterize congenital bilateral torticollis, resulting in sternocleidomastoid tension and limited cervical motion. During intubation, asymmetry in the face caused a mismatch between the facial and cervical midlines, making sniffing difficult. The most difficult aspect of this case was determining the best neck position for intubation. Airway anesthesia is the most important aspect to attenuate airway reflexes and to facilitate awake intubation, especially in difficult situations like this. In this case, the glottic view using video laryngoscope may have been obscured due to musculoskeletal changes. Fiber-optic bronchoscope provided a better view of the glottis.
| Conclusion|| |
Successful anesthetic management in a case of congenital bilateral torticollis requires thorough knowledge about the anatomical changes and also the expertise in fiber-optic bronchoscopy.
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.
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Conflicts of interest
There are no conflicts of interest.
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