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 Table of Contents  
LETTER TO EDITOR
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 30-31

Undetected mass in vallecula: Failure of airway management


1 Department of Anaesthesia and Critical Care Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
2 Department of ENT, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India

Date of Web Publication24-Apr-2019

Correspondence Address:
Dr. Jay Prakash
205, Roma Pearl Apartment, AECS Layout A Block, Kundalahalli, Bengaluru - 560 037, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_18_18

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How to cite this article:
Prakash J, Rao NS, Prabhu J P, Sareen S. Undetected mass in vallecula: Failure of airway management. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2018;2:30-1

How to cite this URL:
Prakash J, Rao NS, Prabhu J P, Sareen S. Undetected mass in vallecula: Failure of airway management. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2018 [cited 2019 Sep 18];2:30-1. Available from: http://www.aiaohns.in/text.asp?2018/2/2/30/256991



Sir,

Undetected extended arteriovenous malformations (AVMs) in the neck due to their anatomical location may cause disastrous airway compromise. We agree with the conclusion of Cook and MacDougall-Davis[1] that avoidance of airway complication requires institutional and individual preparedness, careful assessment, good planning and judgment, good communication, teamwork, and willingness to stop performing when they are failing.

A 12-year-old male child weighing 22 kg was posted for excision of AVMs on the right side of the neck and forehead with ligation of feeding vessel under general anesthesia. The patient was admitted for the complaint of dysphagia. On physical examination, nontender swellings were present on the forehead and anterior aspect of the neck. His routine hematological examinations were within normal limits. The Doppler ultrasound confirmed AVMs in the neck between the carotid arteries and jugular veins. Airway examination showed full mouth opening with adequate neck extension and Mallampati Grade II with normal mentohyoid and mentothyroid distances. Written informed consent was taken as per the routine protocol. After instituting routine monitoring such as electrocardiogram, noninvasive blood pressure, and pulse oximetry, the patient was preoxygenated with 100% oxygen for 3 min. Injection glycopyrrolate 0.1 mg was used for premedication and fentanyl 50 μg was given. Anesthesia was induced with a calculated dose of propofol (total dose 50 mg). As mask ventilation (MV) was possible with normal end-tidal CO2, injection vecuronium (2 mg) was given. During laryngoscopy with Macintosh blade 2, only a mass was observed in the vallecula [Figure 1]; we were unable to visualize the vocal cord even after we tried with McCoy blade. Manipulation of larynx by backward, upward, and rightward pressure, side-to-side movement, and positioning of the patient on shoulder roll, did not help. During preanesthetic checkup, the mass could not be visualized even after adequate mouth opening and hence we missed it; the surgeon also was unaware of it. Insertion of laryngeal mask airway was technically difficult and we failed to achieve its proper placement.
Figure 1: A mass in the vallecula

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In consultation with the otorhinolaryngologist, it was observed that extensions of AVMs were present in the neck, and we planned to postpone the case because we were not prepared at that time. Neuromuscular block was reversed after 40 min of MV and the patient was shifted from the operation theater when fully awake.

AVMs may involve some sites in the upper airway and may be quite extensive. They can involve the base of the tongue, pharynx, supraglottic larynx, and trachea. They most commonly occur in supraglottic larynx followed by trachea. In these locations, they can cause varying degrees of airway obstruction. Large lesions may cause airway obstruction, voice changes, and bleeding and hence may require active intervention.[2]

This case highlights the fact that in the absence of radiological support, fiberoptic bronchoscope, and without full preparedness, analysis of airways complications identifies areas where the practice is suboptimal. To improve outcome, understanding, prevention, and management of such complication remain an anesthetic priority.

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.
Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth 2012;109 Suppl 1:i68-85.  Back to cited text no. 1
    
2.
Jacobs IN, Cahill AM. Special considerations in vascular anomalies: Airway management. Clin Plast Surg 2011;38:121-31.  Back to cited text no. 2
    


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