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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
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Table of Contents
CASE REPORT  
Year : 2011  |  Volume : 14  |  Issue : 3  |  Page : 211-213
Successful double lumen tube insertion in a patient with unanticipated laryngeal and tracheal web


1 Department of Anaesthesiology and Intensive Care, G. B. Pant Hospital, New Delhi, India
2 Department of GI Surgery, G. B. Pant Hospital, New Delhi, India

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Date of Submission05-Feb-2011
Date of Acceptance14-Jun-2011
Date of Web Publication20-Aug-2011
 

   Abstract 

A 45-year-old female patient admitted for surgical management of carcinoma esophagus, presented with difficulty in insertion of left-sided 37 F and 35 F double lumen tube (Mallinckrodt® Broncho-Cath). Fiberoptic bronchoscopy revealed a subglottic web in the larynx just below the vocal cords and a tracheal web just above the carina. Differential lung ventilation could be achieved with a 35 F internal diameter double lumen tube (Portex® Blueline® Endobronchial tube).

Keywords: Difficult intubation, double lumen tube, laryngeal and tracheal webs

How to cite this article:
Virmani S, Uppal R, Kiro K, Bhandari H, Dutta D, Singh N, Aggarwal A. Successful double lumen tube insertion in a patient with unanticipated laryngeal and tracheal web. Ann Card Anaesth 2011;14:211-3

How to cite this URL:
Virmani S, Uppal R, Kiro K, Bhandari H, Dutta D, Singh N, Aggarwal A. Successful double lumen tube insertion in a patient with unanticipated laryngeal and tracheal web. Ann Card Anaesth [serial online] 2011 [cited 2019 Nov 17];14:211-3. Available from: http://www.annals.in/text.asp?2011/14/3/211/84022



   Introduction Top


Laryngeal and tracheal webs are a rare finding and asymptomatic patients are usually diagnosed during unanticipated difficult intubation. [1] This is the first case report wherein a patient with both laryngeal and tracheal webs was successfully intubated with a double lumen tube (DLT).


   Case Report Top


A 45-year-old female patient weighing 50 kg was admitted for surgical management of carcinoma esophagus (mid third). She had no history of any previous surgery and had never been intubated previously. She did not have any other systemic illness such as diabetes, tuberculosis, hypertension, asthma, and arthritis. Routine laboratory data including complete hemogram, serum electrolytes, and kidney and liver function tests were normal. Her chest X-ray revealed normal lung fields, and thoracic magnetic resonance imaging (section below clavicle) exhibited no involvement of the respiratory tract. Her preoperative airway assessment revealed limited view of anterior and posterior pillars (Mallampatti class II).

The surgery planned was McKeown's resection and reconstruction and required differential lung ventilation. The patient was premedicated with pethidine 25 mg and promethazine 25 mg intramuscularly 1 h prior to surgery. In the operating room, after securing an intravenous line, the patient received an additional intravenous dose of midazolam (2 mg) and fentanyl (100 μg). Thereafter, an epidural catheter was placed at the T 7 -T 8 level and general anesthesia was induced with 1% propofol (100 mg). Rocuronium bromide (40 mg) was given to facilitate endotracheal intubation. Resistance was encountered just below the vocal cords during advancement of a left-sided 37 F Broncho-Cath. Therefore, a smaller size (35 F) Broncho-Cath was inserted. Resistance was encountered, but it was possible to negotiate it below the vocal cords.However, resistance was encountered again as the tube was advanced further down the trachea. The tube was withdrawn and fiberoptic bronchoscopy was performed. A subglottic web was visualized on the posterior aspect of the larynx just below vocal cords at the 5 o'clock to 12 o'clock position [Figure 1]. Lower down another web was visualized in the trachea just above the carina on the anterolateral aspect from the 7 o' clock to 12 o' clock position [Figure 2]. Further down, the right and left bronchi were normal in anatomy and caliber. The arytenoids, vocal cords and epiglottis were normal, although there was evidence of injury to the mucosa and signs of inflammation due to repeated manipulation. Finally, a left-sided 35 F DLT (Portex) was positioned successfully. The position was confirmed both by auscultation and by fiberoptic visualization.
Figure 1: Laryngeal web on the posterior aspect of the larynx just below the vocal cords. Also visible are signs of inflammation and bleeding due to repeated manipulation of the endotracheal tube

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Figure 2: Tracheal web above the carina extending from the 7 o'clock to 12 o'clock position

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The intraoperative period was uneventful. After closing the chest, DLT was replaced with a 7.0 mm ID, cuffed single lumen endotracheal tube. In the postoperative period, the patient was electively ventilated for 24 h in lieu of trauma to the respiratory passage with repeated attempts at intubation. Further postoperative period was uneventful.


   Discussion Top


Laryngeal and tracheal webs can be congenital or secondary to inflammation or injury. [1] Congenital laryngeal webs, account for about 5% of the congenital anomalies of the larynx [2] with 75% occurring at glottis and the rest being supra and subglottic in location. [3] On the other hand, there are very few cases reported on tracheal web and incidence is not known. [4],[5],[6],[7] Webs are often known to cause signs and symptoms such as stridor, dyspnoea, use of accessory muscles, and even failure to thrive. [5],[7],[8] Although one might suspect webs in patients with congenital anomalies, in asymptomatic patients, preoperative recognition of webs may be difficult or impossible (just as in this patient). In such patients, the diagnosis is usually made as a coincidental finding during attempted difficult intubation. [9],[10] Thus, webs should be considered a possibility and a fiberoptic bronchoscopy should be considered in all cases of inability to intubate wherein laryngoscopy reveals a normal glottic opening and the exposure of larynx is not difficult. [11] The authors further emphasize the need to maintain gentleness while advancing an endotracheal tube whenever any resistance is encountered. The use of undue force can cause trauma worsening the airway obstruction and posing difficulty with subsequent fiberoptic visualization.

Previous case reports of laryngeal webs reveal that most of these cases have been managed by placing a smaller size endotracheal tube. Cases where endotracheal tube could not be advanced, required emergency tracheostomy. [11] In our patient, the laryngeal and tracheal webs were an unsuspected coincidental finding which created an obstacle to the DLT insertion. Attempts with Broncho-Cath (37 F and 35 F) failed. It is a well established fact that the tubes that are used for lung separation, such as the DLT and the Univent tube are termed difficult (to insert) tubes because they have an increased outer diameter (which makes them relatively difficult to place into a hole of a given size), and an increased overall rigidity (which impairs the optimal shaping of the tube). [11] Since this patient required differential lung ventilation, an attempt was made with Portex DLT (which passed successfully. Portex (and not Broncho-Cath) DLT of the same size (35 F) could be inserted probably because of a gentle angulation and curvature of the tip, and a possible favorable angulation, thereby facilitating successful insertion [Figure 3].
Figure 3: The two double lumen tubes-35 F Mallinckrodt® Broncho-Cath and 35 F internal diameter Portex® Blueline® Endobronchial tube (with gentle angulation and curvature of the tip, and a favorable angulation of the tracheal opening)

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Resection and augmentation of webs are reserved in symptomatic patients for thicker and longer strictures. [1] In view of lack of symptoms, no further management was indicated in this patient. However, the patient was counseled for the possibility of potential problems during any future intubation.


   Conclusion Top


This case illustrates the unusual finding of a laryngeal and tracheal web in the same patient who was successfully intubated using a Portex DLT where an attempt to intubate with a Broncho-Cath DLT failed, possibly because of the amenable curvature and angulation of the proximal end of the former.

 
   References Top

1.Cummings CW, Haughey BH, Thomas JR, Harker LA, In Cummings Otolarygology. Head and Neck Surgeries. 4 th ed. Philadelphia: Elsevier Mosby Inc; 2005.  Back to cited text no. 1
    
2.Holinger PH, Brown WT. Congenital webs, cysts, laryngoceles and other anomalies of the larynx. Ann Otol Rhinol Laryngol 1967;76:744-52.  Back to cited text no. 2
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3.Benjamin B. Chevalier Jackson lecture. Congenital laryngeal webs. Ann Otol Rhinol Laryngol 1983;92:317-26.  Back to cited text no. 3
[PUBMED]    
4.Legasto AC, Haller JO, Giusti RJ. Tracheal web. Pediatr Radiol 2004;34:256-58.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Holinger PH, Johnston KC, Bassinger CE. Benign stenosis of trachea. Ann Otol Rhinol Laryngol 1950;59:837-59.  Back to cited text no. 5
    
6.Altman KW, Wetmore RF, Marsh RR. Congenital airway abnormalities in patients requiring hospitalization. Arch Otolaryngol Head Neck Surg 1999;125:525-8.   Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Miller BJ, Morrison MD. Congenital tracheal web: A case report. J Otolaryngol 1978;7:218-22.  Back to cited text no. 7
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8.Colgan FJ, Keats AS. Subglottic stenosis: A cause of difficult intubation. Anesthesiology 1957;18:265-9.   Back to cited text no. 8
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9.Chong ZK, Jawan B, Poon YY, Lee JH. Unsuspected difficult intubation caused by a laryngeal web. Br J Anaesth 1997;79:396-7.  Back to cited text no. 9
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10.Capistrano-Baruh E, Wenig B, Steinberg L, Stegnjajic A, Baruh S. Laryngeal web: A cause of difficult endotracheal intubation. Anesthesiology 1982;57:123-5.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Benumof J. Difficult tube and difficult airways. J Cardiothorac Vasc Anesth 1998;12:131-2.  Back to cited text no. 11
    

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Correspondence Address:
Sanjula Virmani
Department of Anaesthesiology and Intensive Care, G. B. Pant Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.84022

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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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