Management of acute airway compromise secondary to cricoid chondroma

Summary

The presentation of acute and rapidly deteriorating airway pathology can be a highly challenging situation for any hospital team. Cricoid chondromas are a challenging and potentially unfamiliar airway pathology requiring the combined expertise of anaesthetists, ear, nose and throat surgeons and a wider peri‐operative team familiar with managing airway emergencies. Airway lesions which cause rigid and fixed stenosis require careful management and present additional challenges compared to soft tissue lesions. An important consideration in fixed airway stenosis is the external diameter of tracheal tubes compared to the diameter of the airway at its narrowest point. These are challenging cases to manage and a multi‐disciplinary approach to the safe management of unfamiliar and critical airway pathology should be adopted.

Introduction

Chondromas are benign mesenchymal tumours. Chondroma of the larynx is considered uncommon and occurs most frequently in middle‐aged men [1]. The cricoid cartilage is most often the site of origin of laryngeal chondroma, followed by thyroid cartilage, the epiglottis, and the body of the arytenoid [2]. Chondromas cause challenges with a fixed‐orifice airway obstruction that behaves differently to the more common soft tissue airway pathologies. Critical review of chondroma cases is difficult as most reports lack pathological documentation and follow‐up data [3].

Airway management in acutely unwell patients with an anticipated difficult airway can be challenging in any centre. This is particularly true with relatively rare pathologies such as cricoid chondromas. Awareness of clinician experience, assistance, available equipment, backup facilities and the patient's clinical status all contribute towards forming a safe airway management plan. This not only applies to the anaesthetist but to every member of the multidisciplinary team (MDT). Whilst existing airway management algorithms are useful as reminders in emergency scenarios, they lack emphasis on wider team decision‐making involving the whole MDT. Emphasis should be placed on timely discussions to allow for key details and potential risks to be pre‐empted and prepared for, allowing maximum safety in a high‐pressure, potentially time‐critical situation.

Here, we present the case of a patient with a known cricoid chondroma, who presented with acute respiratory compromise.

Case report

A 56‐year‐old man presented to our emergency department with acute stridor and respiratory distress. His background included a known cricoid chondroma under routine surveillance, and chronic obstructive pulmonary disease (COPD). The patient was of slim build and had a large beard reaching his chest. He denied any symptoms of acute respiratory tract infection or any obvious precipitating cause for his clinical condition.

Initial observations at presentation revealed sinus tachycardia of around 110 beats.min⁻¹ and respiratory rate of over 30 breaths.min⁻¹, coupled with increased work of breathing and obvious stridor. No abnormal respiratory lung sounds were noted on auscultation. He was self‐ventilating, and oxygen was delivered at 15 l.min⁻¹ via a non‐rebreathe mask. Airway patency was only maintained with the patient sat completely upright. Three doses of nebulised adrenaline (5 ml of 1:1000 solution) and intravenous dexamethasone 6.6 mg did not yield any clinical improvement.

A flexible nasendoscopy (FNE) performed in the emergency department revealed poor right vocal cord movement but a glottic opening of sufficient size. Structures below the glottis, including at the level of the cricoid were not visible beyond the vocal cords.

An outpatient computerised tomography (CT) scan of the patient's neck (Fig. 1) performed one month before his admission showed that the airway at the level of the cricoid lesion was narrowed to 4 mm in diameter. Repeat imaging was not attempted in the acute setting as the patient could not tolerate lying flat.

Figure 1.

CT scan of the patient taken one month before admission. Image shows the level of C4 cervical sign at the level of the cricoid cartilage. Airway diameter at this level was measured at 4 mm, with associated tumour of the cricoid cartilage.

After careful consideration, and discussions between ear, nose and throat (ENT) and anaesthetic teams, the patient was counselled and consented to an emergency awake surgical tracheostomy under local anaesthesia and intravenous sedation.

Preparations for the procedure were performed in the emergency operating theatre. Routine monitoring including pulse oximetry, non‐invasive blood pressure and three lead ECG monitoring was applied. Large bore intravenous access was secured. The patient was sat at a 45‐degree angle with the neck extended as much as possible, and his beard taped away from the neck using an adhesive dressing. Oxygenation was supplemented using high‐flow nasal cannulae, and sedation was provided using remifentanil via a target‐controlled infusion (Minto model) technique with a maximum effect site target of 1.5 ng.ml⁻¹.

Surgically, a mini‐tracheostomy technique was used [4]. This involved injection of 2% lignocaine with 1:80,000 adrenaline into the skin and subcutaneous tissues, ensuring infiltration of the perichondrium and tracheal lumen. A 2 cm horizontal skin crease incision between the cricoid and sternal notch was made and the straps were bluntly dissected to reveal the trachea. A high horizontal incision was made due to the possibility of future laryngectomy and a size 8 cuffed Portex Blue Line Ultra Cuffed Tracheostomy Tube (Smiths Medical Inc, Minneapolis, United States) was inserted and secured with sutures.

The patient remained calm and comfortable throughout. No adverse events occurred during the surgery and the position of the tracheostomy was deemed satisfactory after being checked with a single‐use bronchoscope. His symptoms and clinical condition rapidly improved post‐procedure and he was transferred to the intensive care unit for observation.

At the time of presentation, there was no obvious cause for the patient's sudden deterioration. During his admission, he was found to be positive for SARS‐CoV‐2 albeit with no clinical or radiological features of COVID pneumonitis. The patient was discharged from the hospital with a tracheostomy in situ and was reassessed as an outpatient three months later. Attempted decannulation failed with the patient becoming stridulous and dyspnoeic requiring the tracheostomy to be promptly re‐inserted.

Discussion

A cricoid chondroma presents a particular challenge in the acute or emergent setting. They are derived from cartilaginous tissue and can cause a fixed orifice, or mechanical obstruction. Nebulised adrenaline and steroids are often used in cases of acute airway obstruction as a temporising measure but in our case of cricoid chondroma, the patient's response to both was limited given minimal airway oedema associated with chondromas.

Insertion of a surgical tracheostomy on an awake patient is a highly challenging scenario for both surgeon, anaesthetist and patient, and is often reserved as an airway rescue attempt. This was made more challenging in our case because the patient could not be positioned optimally due to respiratory distress. Fortunately, the patient had a good understanding of the issues surrounding his presentation, which allowed for shared decision making and counselling. This was only decided after airway management options were discussed as a team.

Although our case was uneventful, there was a high potential for complications. The learning points from this case do not primarily stem from clinical events during the surgery itself but the team‐based discussions and preparations made before the patient arrives in the emergency theatre. In a published study of inconsistencies in the management of airway obstruction, several experts in airway management were asked for their management plans for a specific airway case [5]. Almost every expert suggested a different plan and some advocated for methods that others described as dangerous. Management plans therefore vary greatly depending on the skillset and experience of staff present, as well as the equipment available at the specific centre.

We focused on a combined MDT‐based approach to this case and formulated a management plan with the surgeons and wider peri‐operative theatre team that worked well in our centre. The first decision to make was whether to manage this patient awake or under general anaesthesia. From an anaesthetic point of view, considerations for this decision often centre around four main aspects: the ability to ventilate the patient either with a facemask or using a supraglottic device; ability to achieve tracheal intubation; aspiration risk of patient; and urgency of intervention required.

The findings of the FNE combined with a mechanically fixed airway lesion led us to the following opinions: Bag‐valve‐mask ventilation was predicted to be possible under general anaesthesia provided a seal could be made against a large beard. We felt that apnoeic oxygenation using high‐flow nasal oxygen was another potential approach. However, we identified that the unpredictable aspect of airway management would be how to pass an tracheal tube beyond the obstruction (including whether it is possible at all).

Taking our oxygenation, ventilation and airway predictions as above, we initially considered inducing general anaesthesia and attempting tracheal intubation using a rigid intubating endoscope (Bonfils Intubating Endoscope, Karl Storz GmbH & Co., Tuttlingen, Germany) with a size 4 micro‐laryngoscopy tube (MLT). In cases of soft tissue obstruction, this is a very useful technique, to allow displacement and bypass of the obstruction under direct vision, avoiding potential airway trauma whilst providing rigidity to pass the obstruction. Crucially, the external diameter of a size 4 MLT is 5.6 mm. The surgical opinion suggested that a 5.6 mm diameter tube might pass through a 4 mm fixed stenosis, but it is not guaranteed given the lack of distensibility at the site of the obstruction. Emphasis is usually on internal tracheal tube diameters; in this case, the external diameter was highlighted by the surgical team during MDT discussions.

An awake fibreoptic intubation option was considered. The flexible scope available at our centre was the aScope 4 (Ambu, Ballerup, Denmark). Manufacture guidance is that even with a ‘slim’ model the smallest tube diameter that can be used is 5 mm. Paediatric‐size bronchoscopes are usually available in smaller sizes but were not readily available in our adult centre and also do not have the required length to accommodate an adult‐size MLT. In addition, thinner scopes would also lack any significant rigidity to facilitate the insertion of a tube in an already confined and non‐expandible space.

Jet ventilation was briefly considered but was unanimously decided against by the team. Being in a major head and neck centre, our team was familiar with the technique and had equipment readily available. However, it was judged inappropriate in this case because it would have required the surgical team to maintain and direct the jet stream as well as perform the tracheostomy. This increases surgical complexity on the background of an already difficult tracheostomy. Placement of a jet catheter would also be challenging, together with a possible risk of air entrainment in such a narrowed airway leading to barotrauma.

Emergency front‐of‐neck access would also be challenging, as usual access through the cricothyroid membrane would still be above the level of the obstruction. Given all of the potential options discussed, the surgical team proposed that an awake tracheostomy insertion with local anaesthesia would be the safest approach to this airway. We then considered what our rescue plan would involve should the patient become distressed. As a team, we decided that a rapid sequence induction and a single attempt at tracheal intubation under general anaesthesia with a Bonfils intubating stylet would be acceptable before attempting emergency surgical front‐of‐neck access.

Our plan was discussed together with the wider theatre team present. We also verbally rehearsed the case and plans, so that each team member was prepared for all likely scenarios discussed. This also allowed the relevant equipment to be prepared and placed within the operating theatre in a sequential manner mirroring our surgical management plan.

This report has parallels with the main points of the NAP4 study and reinforces some of the key learning points from the study, including failure to plan for failure and a failure of cooperation between surgeons and anaesthetists. The promotion of MDT‐style discussions around difficult airway management also does not feature in any of the common difficult airway algorithms. Through a thorough but succinct MDT discussion, pre‐established plans for airway management and rescue airway management can be prepared allowing for sequential, rehearsed execution to improve response time. It also helps to promote an atmosphere of calm, improving confidence for all staff involved. As a learning point, we advocate the importance of such discussions in all difficult airway cases and emphasise the enormous clinical benefit of excellent communication and a combined approach to difficult airway management.