Expedited awake tracheal intubation using ropivacaine topicalisation for the evacuation of a postoperative neck haematoma in the presence of lignocaine allergy

Abstract

Progressive airway compromise from a neck haematoma is a feared complication of head and neck surgery that can rapidly lead to death if not urgently intervened upon. We report a case of a patient developing a progressively expanding neck haematoma on the first postoperative night after parotidectomy and neck dissection for malignancy. Although he did not have respiratory compromise or stridor, ultrasound examination of his airway revealed marked tracheal deviation, and flexible nasoendoscopy showed significant supraglottic swelling. The decision was made for an awake fibreoptic intubation; however, a complicating factor was a history of lignocaine allergy. This case report describes the unconventional use of atomised ropivacaine in a concentration of 0.5% for topicalisation of the airway. Along with conscious sedation with remifentanil, ropivacaine provided excellent conditions for awake intubation, following which a significant amount of blood was evacuated from the face and neck.

Background

An expanding neck haematoma can cause progressive upper airway obstruction postoperatively by causing venous congestion leading to supraglottic oedema.¹ This can rapidly lead to death if not intervened on. The Difficult Airway Society (DAS) has recently published a guideline outlining the approach to the management of haematoma after thyroid surgery which can be extrapolated to surgery involving the head and neck.² It is important to stress that stridor is a very late sign of impending airway loss and that techniques to assess the airway appropriately are essential to avoid the need for emergency front of neck access.^{2 3} The use of airway ultrasound is emerging as a new tool in the comprehensive examination of the airway and can help guide optimal choice of intubation.⁴ Repeated attempts at intubation can lead to trauma; it is therefore important to establish early whether the airway needs to be secured awake. Emergent awake intubation is a stressful time for both the clinician and the patient. It is important to prepare for situations that may be non-conventional whether it be for patient, anaesthetic or surgical factors. Lignocaine is the choice of local anaesthetic for the topicalisation of the airway because of its optimal pharmacokinetic profile and low incidence of adverse effects.⁵ It is also available in a variety of formulations such as liquids and gels. In the case of true lignocaine allergy, there are no conventional readily available alternatives for topicalisation. We elaborate on our use of ropivacaine for this purpose, which to our knowledge, has not previously been described in the literature.

Case presentation

A man in his 70s, 86 kg, with a high-grade basaloid carcinoma of the left parotid presented for elective radical parotidectomy, mastoidectomy, ipsilateral neck dissection and static reconstruction with a fascia lata sling. The parotid mass involved the deep lobe without parapharyngeal extension. His history included hypertension and benign prostatic hyperplasia. He was on indapamide, tamsulosin and valsartan. He was not on any anticoagulants preoperatively. He had a background of anaphylaxis to lignocaine after infiltration for a skin lesion many years ago. There was no formal allergy testing, but ropivacaine was used subsequently with no issues. Airway examination revealed a parotid mass extending to the upper neck with no associated trismus and no other concerning features.

Following induction of anaesthesia, bag-mask ventilation was difficult necessitating an oropharyngeal airway and two-handed technique. He was intubated using a videolaryngoscope (McGrath Mac, Minneapolis, USA) with a full glottic view. The operation proceeded for 8 hours after which he was extubated and transferred to the ward after a period of observation in the recovery room. He did not receive pharmacological thromboprophylaxis perioperatively.

Five hours later, he developed increasing left-sided facial swelling which extended over the next few hours to the left eyelid and neck (figure 1). He was transferred to theatre for haematoma evacuation. On formal assessment, dysphagia and mild dysphonia were present, but he was not agitated or in respiratory distress and had no stridor. There was, however, moderate-to-severe trismus due to facial swelling. A bedside airway ultrasound revealed marked right tracheal deviation with a collection in the left neck. Given these findings, flexible endoscopic laryngeal assessment was planned.

Figure 1.

Facial and neck swelling pre-induction.

Due to the documented lignocaine allergy, ropivacaine 1% (11 mL) and epinephrine 1:1000 (0.2 mL) were used to create a solution of 0.5% ropivacaine with 10 mcg/mL of epinephrine, using 0.9% saline as the diluent (to a total of 22 mL). The right nostril was topicalised with this solution and nasoendoscopy was performed which demonstrated marked supraglottic oedema with a poor glottic view. Due to anticipated airway difficulty in the setting of a cooperative patient with maintained spontaneous ventilation, an awake fibreoptic intubation was planned, and the otorhinolaryngology surgeon was asked to be ready for front-of-neck access in the event of failure.

Oxygenation was provided via high-flow nasal prongs (50 L/min) and remifentanil sedation administered (Minto model at 2 ng/mL effect site concentration). Topicalisation was achieved using an atomiser (EZ-spray, Utah, USA) with a solution of 0.5% ropivacaine to a total of 22 mL. Serial right nasal dilation was conducted using soft nasopharyngeal airways. After a period of 15 min, there was good loss of gag reflex and deepening of voice tone. A size seven nasal Ring-Adair-Elwin (RAE) tracheal tube was inserted via the right nostril to 12 cm and a bronchoscope (AmbuaScope, Copenhagen, Denmark) was passed through its lumen to achieve a view of the larynx. The glottis was traversed, and the trachea intubated. After confirmation of end-tidal CO₂, anaesthesia was induced, and 300 mL of blood was evacuated from the face and neck, with a culprit angular facial artery identified and ligated, together with two smaller bleeds within the neck. Intraoperative dexamethasone (12 mg) and tranexamic acid (1 g) were also initiated.

In view of significant supraglottic oedema, he was transferred to the intensive care unit intubated. He was given regular intravenous dexamethasone and nursed in a head-up position. He was extubated successfully after 48 hours (figure 2).

Figure 2.

Resolution of facial and neck swelling post-extubation.

Outcome and follow-up

On debriefing with the patient in the following few days, he could not recollect much of the awake intubation and felt relatively comfortable during the whole process. He has subsequently been referred for formal lignocaine allergy testing.

Discussion

The incidence of neck haematomas after major head and neck surgery is approximately 3.4%.⁶ A rare but potentially fatal complication of postoperative neck haematomas is upper airway obstruction and subsequent respiratory compromise.^{1 2} The pathophysiological mechanisms of airway compromise include the mass effect of the haematoma on surrounding upper airway structures, compression of low-pressure venous and lymphatic vessels impairing drainage from the head, and the redistribution of blood with rising compartment pressures into communicating head and neck spaces.¹ Unilateral neck haematomas can mechanically displace the laryngeal inlet away from midline, as seen in our case. The major devastating consequence of a neck haematoma is laryngopharyngeal lymphovenous oedema, which is often out of proportion to the degree of externally visible neck swelling.¹ Furthermore, there is an element of blood dissection along the parapharyngeal space which is continuous with the retropharyngeal space, which can cause airway compromise by compression of the arytenoid cartilages.¹

Prompt recognition and management of a postoperative neck haematoma is essential in order to avoid morbidity and mortality.^1–3 The DAS has recently published a guideline outlining the approach to management of haematoma after thyroid surgery which can be extrapolated to surgery involving the head and neck.² It is important to stress that stridor is a late sign of impending airway loss and that techniques to assess the airway appropriately are essential for appropriate airway planning and to avoid the need for emergency front-of-neck access.^{2 3} In our case, apart from significant facial swelling and associated trismus, dysphagia and mild dysphonia were the only symptoms suggestive of early airway compromise. However, an unpredictable critical point can be reached that results in sudden airway compromise, often heralded by patient agitation, tachycardia, increased work of breathing and stridor.

Even though the patient’s anatomy presented no significant difficulty with intubation the day before, the presence of significant facial swelling and neck haematoma resulted in significant distortion of baseline anatomical features. Investigative options to define the extent of the haematoma are limited in this scenario, and CT with angiography is not recommended in this setting where rapid clinical deterioration is possible. The utility of pre-operative point-of-care airway ultrasound becomes important here. Airway ultrasound using a high-frequency linear probe is a valuable, non-invasive, simple and portable point of care technique for airway evaluation. There is emerging interest in the literature regarding its utility in the prediction of difficult airways, providing the ability to plan the optimal method of intubation, increasing patient safety.⁴ It has proven efficacy over landmark technique with identifying the cricothyroid membrane in anticipation of a front-of-neck access.⁷ In our case, airway ultrasound was useful in the recognition of tracheo-laryngeal deviation signifying a significant neck haematoma, warranting further evaluation of middle column pharyngeal and laryngeal structures. In addition, it allowed for location of the cricothyroid membranes and trachea in case emergency front-of-neck access was required.

Lignocaine is the most widely used agent for the topicalisation of the airway for awake intubation. It is available in a variety of formulations to facilitate topicalisation and can be used in combination with epinephrine to provide vasoconstrictor activity particularly with nasal instrumentation.^{5 8} Cocaine, at 1.5 mg/kg, is an alternative for topicalisation, has the benefit of intrinsic vasoconstriction activity, but there are concerns regarding toxicity and is not readily available.^{5 8} Lignocaine allergy, although rare, poses a challenge when encountered in a situation requiring awake intubation. While awake fiberoptic intubation using sedation alone has been advocated by some groups, it was not deemed to be appropriate in this scenario.⁹ Sedation, however, may assist patients in tolerating topicalisation techniques.

To our knowledge, there has been no literature describing the use of ropivacaine for topicalisation prior to awake intubation; however, a recent randomised controlled trial highlighted the efficacy of airway atomised 0.75% ropivacaine in the reduction of extubation response.¹⁰ This study atomised 6 mL of 0.75% ropivacaine after induction of general anaesthesia and prior to intubation. The maximum recommended dose of ropivacaine is quoted as 3 mg/kg and considering that a significant amount of the drug would be swallowed and undergo first pass metabolism, the use of this limit for topicalisation of the airway was considered safe. In our case, we delivered a total of 22 mL of 0.5% ropivacaine (110 mg), which was well within the 3 mg/kg, and the intubation was tolerated well, with dose titrated to critical endpoints of loss of gag reflex and change in voice. Ropivacaine offers a degree of intrinsic vasoconstrictor activity; however, epinephrine was added to give a concentration of 10 mcg/mL, in order to further reduce the risk of nasal bleeding, which could make the fibreoptic intubation even more difficult in an already challenging situation. It also has the theoretical benefit of reducing mucosal absorption of ropivacaine.¹¹

An oral fibreoptic intubation would have obviated the need for nasal topicalisation and dilation, and arguably could have been faster given the shorter course into the airway.¹² However, the nasal route, over oral, was chosen for several reasons. The evolving haematoma under the fascia lata sling resulted in moderate-to-severe trismus and buccal swelling, which limited oral access. In addition, we had already performed a nasoendoscopic examination using fibreoptic bronchoscopy, which revealed laryngotracheal deviation to the right. The use of the right nasal route therefore assisted fibreoptic guidance towards the deviation. The oral route would also have required a bite block, such as the ovassapian intubating airway, which may not have seated appropriately given swelling in the oral cavity. Furthermore, it would have hindered directing the fibreoptic bronchoscope away from the midline into the deviated airway.

This case illustrates the importance of recognition of impending airway compromise in the setting of postoperative expanding neck haematoma, and it outlines the utility of airway ultrasound as part of a comprehensive airway assessment. We report the novel use of ropivacaine in topicalisation of the airway for awake intubation, which is a good alternative in the setting of lignocaine allergy.

Learning points.

• In the setting of an expanding postoperative neck haematoma, stridor is a late sign of impending airway loss, and so techniques to assess the airway such as ultrasound are encouraged for appropriate airway planning.

• Airway ultrasound is a useful modality for the recognition of tracheo-laryngeal deviation signifying a significant neck haematoma.

• Ropivacaine, at a concentration of 0.5%, is a good alternative for use in topicalisation of the airway for awake intubation in patients with lignocaine allergy.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).