Unexpected difficult airway management in a transgender female patient

Summary

A transgender female patient, who had previously undergone gender‐confirming feminisation surgery to the face and larynx, was scheduled for thoracic surgery requiring one‐lung ventilation. We encountered unexpected difficult airway management and difficulty inserting an appropriately‐sized double‐lumen tube. A size 41Fr double‐lumen tube, which is selected commonly for biological males, was used eventually for lung isolation and subsequently exchanged for a size 6.5 single‐lumen tracheal tube at the end of the case, before successful extubation with a staged extubation set. It is important to highlight the challenges faced, as the care of transgender patients is likely to be unfamiliar to most anaesthetists, despite the increase in the number of gender‐confirming procedures performed. Many of these procedures involve the face and airway and can result in significant challenges for airway management, including appropriate sizing of tracheal tubes and their correct placement. It is also possible that patients may not volunteer a history of these procedures and it should be enquired about specifically as part of the anaesthetic pre‐assessment.

Introduction

The term transgender is used to describe people who identify with a different gender to the one they were assigned at birth. The American Society of Plastic Surgery reports that 3256 transgender patients underwent surgical procedures in 2016, following an approximately 3.5‐fold increase in the United States over the preceding decade ^{1, 2}. Although similar data are not available in the UK, this trend suggests that looking after transgender patients is going to be something that clinicians and other healthcare providers will increasingly need to be familiar with.

The peri‐operative pathway can be stressful for transgender patients and clinicians should be prepared to alleviate this wherever possible throughout the journey. There are also several specific medical concerns that clinicians need to be aware of, as these can impact the treatment and care provided. Unless aspects of gender‐confirming treatment, including medications and surgical procedures, are enquired about as part of routine medical assessment, clinicians may find themselves faced with unexpected challenges due to the anatomical and physiological changes this group of patients may have undergone.

Report

A 51‐year‐old transgender female was scheduled to undergo sternotomy for thymectomy and left upper lobe wedge resection. To facilitate surgery, a double‐lumen tube (DLT) was required to provide lung isolation. The patient had a history of thrombocytopenia secondary to human immunodeficiency virus (HIV). In addition, there was a history of facial feminisation surgery; mandibular reconstruction; vocal cord tightening (glottoplasty); and thyroid cartilage reduction, none of which were disclosed at assessment during the pre‐operative visit.

Following induction of anaesthesia with plasma‐concentration target‐controlled infusions of propofol and remifentanil and 1 mg.kg⁻¹ intravenous rocuronium, we encountered unanticipated difficult airway management. Firstly, facemask ventilation and basic airway manoeuvres were difficult, due to restricted movement of the mandible. Secondly, we encountered difficult laryngoscopy with a view of the epiglottis only using a C‐MAC^® (KARL STORZ Ltd, Slough, UK) videolaryngoscope with a size 4 Macintosh blade (Fig. 1a). This improved to a view of the arytenoid cartilages and the posterior aspect of the glottic opening with a D‐blade (Fig. 1b). Finally, tracheal intubation and correct placement of a size 37Fr DLT proved to be difficult due to tight vocal cords with a small glottic opening. In the first instance, a 37Fr DLT was placed but views with a flexible bronchoscope identified the size as too short to achieve lung isolation. We tried instead a 39Fr DLT and the same problem was encountered, before a 41Fr DLT was placed with difficulty, and a very snug fit within the glottis was viewed with the videolaryngoscope. The 41Fr DLT was used during the surgical procedure, but once one‐lung ventilation was no longer required, the DLT was exchanged over a bougie to a size 6.5 single‐lumen cuffed tracheal tube. Dexamethasone was administered to reduce airway swelling and adrenaline sprayed directly onto the vocal cords, and once an audible leak was detected, the patient was successfully extubated using a staged‐extubation technique with the wire left in situ and taped to the patient's face in the intensive care unit for 24 h. Recovery was uncomplicated and an airway alert form was completed thereafter.

Figure 1.

Images obtained during videolaryngoscopy with a C‐MAC using: (a) MAC 4 blade; (b) D‐blade.

The patient was scheduled for removal of sternal wires approximately 6 months later when lung isolation was not required. On this occasion, a size 7.0 cuffed tracheal tube was sited using a C‐MAC videolaryngoscope with a D‐Blade and with no audible leak following deflation of the cuff.

Discussion

There are ~200,000–500,000 transgender people living currently in the UK ³. There is nevertheless relatively little published in the anaesthetic literature addressing the peri‐operative care of a transgender patient undergoing surgery not related to gender re‐assignment, nor is this covered by the Royal College of Anaesthetists 2010 training curriculum in anaesthesia in the UK ⁴. In addition, there appears to be a significant increase in the number of gender re‐assignment procedures being performed ¹.

A recent review by Tollinche and colleagues outlines several aspects of peri‐operative care that should be addressed when caring for a transgender patient ². Firstly, it is important to precisely outline the difference between the terms ‘sex’ and ‘gender’. The former refers to physical differentiation based upon genetics and physical characteristics, including internal and external genitalia, whereas the latter is a social phenomenon related to cultural expectations, perceptions and behaviours. We argue more work is required to address the way this information is collected by organisations, including healthcare organisations, and how staff members use this to communicate with and treat patients.

Secondly, the use of gender‐confirming hormone therapy and the physiological and pharmacological consequences of such treatments should be considered. Patients are likely to be taking either hormone supplementation or hormone‐modifying medication, which can interact with anaesthetic drugs. The use of exogenous oestrogens also significantly increases the risk of venous‐thromboembolism ². Laboratory tests can be affected by medical treatment and may need to be requested based upon the biological sex or values interpreted in this context, including pregnancy testing in transgender men and prostate‐specific antigen testing in transgender women ⁵.

There are also important anatomical considerations resulting from gender‐confirming surgical procedures. These comprise a wide spectrum of features depending on what degree of gender re‐assignment has occurred and may not be immediately obvious or disclosed on pre‐operative assessment. The incidence of these procedures is difficult to ascertain as different clinicians may be involved in performing gender‐confirming procedures including: plastic and reconstructive surgeons; urologists; gynaecologists; and aesthetic practitioners. Commonly, surgery involving the urethra will have been performed, which may necessitate either a smaller catheter than expected or placement by a urologist or other specialist with experience in transgender anatomy ².

Procedures involving the face, jaw and airway are less common, but have obvious relevance to the anaesthetist. A systematic review has suggested that vocal cord shortening procedures are the most common and most effective for increasing voice pitch ⁶. Available techniques include: cricothyroid approximation to increase vocal cord tension; vocal cord shortening; using a laser or other instruments to de‐epithelialise the anterior third of both vocal cords and suturing together to form an anterior glottic web; and laser reduction glottoplasty to decrease vocal cord mass ^{6, 7}. The presence of an anterior glottic web with posterior displacement of the anterior commissure, possible decreased mobility of the vocal cords, and altered cricothyroid distance are likely to increase the difficulty of tracheal tube placement and may necessitate a smaller tube size with careful atraumatic placement to avoid airway oedema and bleeding.

There are a wide range of procedures that can be performed to alter the shape of the face and jaw ⁸. Alteration of the forehead and hairline can be performed as part of both masculinisation and feminisation with the aim to create a realistic brow, and the nose is often altered at the same time. Of more relevance to anaesthesia are procedures to the chin and jaw performed as part of feminising the lower face. The height of the female jaw is typically 20% shorter than in males, and therefore reducing the jaw height along with width is a key part of confirming feminisation ⁹. T‐osteotomy of the chin, which involves splitting the mandible in the midline and removing a t‐shaped piece of bone to decrease the height of the mandible, is usually required. Scar tissue in this area is likely to reduce movement of the mandible and may make mask ventilation challenging. In addition, this procedure will result in a shorter thyromental distance with a reduced mandibular space, which makes the axis of the larynx less likely to line up with the pharyngeal axis and increase difficulty of tracheal intubation. Surgery to alter the size of the thyroid cartilage can also be performed via a submental incision. The practice of decreasing the size of the thyroid cartilage in feminisation is widely accepted, but in masculinisation the cartilage can also be increased in size, by using a graft of rib cartilage. Scar tissue from these procedures can lead to problems with mask ventilation and tracheal intubation.

Finally, there are a wide range of other psychological and social issues that require addressing in order to provide high‐quality care for transgender patients. Many issues such as mood disorders; substance abuse; HIV infection; and sexually transmitted infections have higher rates in the transgender population, contributed to by experiences of transphobia, stigmatisation and micro‐aggression ². These can be exacerbated by healthcare encounters, and familiarisation with guidance on expected standards of care is recommended for all clinicians ¹⁰.

In conclusion, this case highlights several challenges facing anaesthetists providing peri‐operative care to transgender patients. In addition, there is the specific problem of achieving one‐lung ventilation in a patient who has had gender‐confirming surgery to the face and larynx. We argue for more awareness of these issues, especially given the paucity of coverage in anaesthetic training curricula. The likelihood of clinicians needing to provide care for transgender patients undergoing surgery unrelated to gender‐confirmation is increasing.