Laryngoscopy and Microlaryngoscopy

Case Synopsis

A 62-year-old obese man (body mass index 41) with a history of laryngeal cancer presents for microdirect laryngoscopy, esophagoscopy, and bronchoscopy to evaluate a positron emission tomography (PET)–positive lesion on recent surveillance scanning. He has a history of chronic obstructive pulmonary disease on 2 L home oxygen, hypertension, hyperlipidemia, 35 pack-year smoking, and laryngeal cancer for which he underwent transoral robotic surgery and subsequent radiation. He underwent nasopharyngolaryngoscopy in the surgical clinic, which demonstrated no overt mass and significant laryngeal edema and scarring. After induction of general anesthesia with propofol and remifentanil, mask ventilation is difficult but adequate to maintain oxygen saturation greater than 90%. The airway is immediately turned over to the ear, nose, and throat (ENT) specialist. Surgical laryngoscopy with a Jackson laryngoscope provides no view of the larynx. Mask ventilation is resumed and subsequent exposure with an anterior commissure scope is sufficient to introduce a 4% lidocaine laryngeal tracheal applicator and a metal suction catheter through the glottic opening. High-frequency jet ventilation is initiated through the metal suction catheter (frequency 120, driving pressure 22 psi, inspiratory time 40%, Fio ₂ 100%). Hypotension (blood pressure 90/50 mm Hg) and bradycardia (heart rate 48 beats per minute) are treated with 10 mg of intravenous ephedrine, and the procedure is completed with no biopsies or bleeding. A 6.0 endotracheal tube is placed through the anterior commissure scope by the surgeon, and the patient is extubated after fully awake. A difficult airway bracelet is applied, and the patient is taken to the recovery area.