Paratracheal compression to prevent aspiration in a patient with an undiagnosed vascular neck mass: Quick detection and improvisation - A case study

Dear Editor,

Aspiration of the oral or gastric contents into the lung can occur because of decreased level of consciousness, compromised airway reflexes, and recurrent vomiting, especially in traumatic brain injury (TBI) patients.[1] We report an alternate paratracheal pressure (PTP) technique to prevent aspiration.

A 70-year-old female patient with no known comorbidities presented to the emergency unit with an alleged history of road traffic accident. The patient had altered sensorium, and multiple episodes of vomiting since the accident. Non-contrast computed tomography of the head revealed an epidural haematoma with midline shift and mass effect and effacement of the ipsilateral ventricle. The patient was scheduled for an emergency craniotomy and evacuation of the haematoma. On arrival at the operation theatre, the patient had a Glasgow Coma Scale (GCS)-E₂V₂M₅, breathing spontaneously and maintaining normal vitals. On examination, a soft pulsatile swelling just below the thyroid cartilage, slightly towards the right side of the neck, was noticed [Figure 1a]. A ultrasound examination revealed a vascular pathology [Figure 1b]. Since the mass was in the mid-line, applying cricoid pressure posed a risk of compression and injury to the underlying vessel. Additionally, the patient had an unknown fasting status with all features of raised intracranial pressure (ICP), so the aspiration risk was of concern. Therefore, after giving intravenous ranitidine 50 mg, and metoclopramide 10 mg, the anaesthesia was induced with intravenous propofol 120 mg and rocuronium 70 mg. Then, left-sided PTP was given until the trachea was intubated and the cuff was inflated [Figure 1c]. Figure 1c is a representative image that shows the application of PTP in a different patient. Upon laryngoscopy, the patient had a Cormack Lehane (CL) grade-2 and a percentage of glottic opening (POGO) score of 80%.

Figure 1.

(a) Shows the neck mass on the right side (yellow circled and black arrow marked), (b) The ultrasound image of the swelling showing arterial flow, (c) Representational image of application of left paratracheal pressure in another patient

Aspiration pneumonia is a significant non-neurological complication that accounts for TBI patients’ mortality. Cricoid pressure has been used as a rapid sequence intubation technique component. However, as the oesophagus might not be directly behind the cricoid cartilage, applying cricoid pressure can result in incomplete obstruction.[2] The compression of the pulsatile neck mass during the cricoid pressure can cause injury of the underlying vessels and lead to a cardiovascular collapse. It can also cause various haemodynamic changes, including severe bradycardia and hypertension due to carotid sinus stimulation.

Alternatively, it was found in a study that the application of PTP was more effective than cricoid pressure in occluding the oesophagus or preventing the entrance of air into the stomach during mask ventilation.[3] Regarding the effect on the laryngoscopic view, a study demonstrated that PTP is non-inferior to cricoid pressure as measured by modified CL and POGO score.[4] Moreover, PTP may be less affected by external laryngeal manipulation, as manipulation sites are relatively far from each other. Hence, applying paratracheal pressure in such a patient as an alternative to cricoid pressure can prevent many anticipated and unanticipated complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.