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///2010 Abstract Details
2010 Abstract Details2019-08-03T15:49:10-05:00

A Case of Unanticipated Difficult Airway After Induction of Anesthesia for Cesarean section

Abstract Number: 190
Abstract Type: Case Report/Case Series

Debebe Fikremariam MD1 ; James L Sadler MD2; Mathew Ellison MD3

A Case of Unanticipated Difficult Airway After Induction of Anesthesia for Cesarean section

Case description

A 37 year old G 7 P 2 at a gestational age of 37 2/7 weeks was referred to our facility because of poorly controlled diabetes mellitus, asthma, breech presentation and polyhydraminos for cesarean section. General endotracheal anesthesia with a rapid sequence induction was performed after several failed spinal attempts. Direct laryngoscopy revealed a 1.5 to 2 cm paraglotic mass, obscuring the laryngeal inlet resulting in an esophageal intubation prior to a successful blind tracheal intubation. Intra-operative ENT recommendation was to give dexamethasone 10 mg intravenously to counteract possible airway edema. The trachea was extubated over an airway exchange catheter with the patient awake and following commands. Post operatively patient and neonate did well. Subsequent ENT evaluation revealed the diagnosis of anterior tonsillar pillar papilloma.


We present a case of unanticipated difficult airway secondary to supraglottic mass. In such cases the endotracheal tube can be used to push the mass away from the glottic opening and intubate the trachea. Aspiration can be attempted on cystic masses detected before induction of anesthesia. The trachea can also be intubated over gum-elastic bougies. Repeated attempts at intubation should be limited to prevent hemorrhage and/or edema which could lead to a "can not intubate, can not ventilate" situation. The American Society of Anesthesiologists difficult airway algorithm lists laryngeal mask airway, esophageal-tracheal combitube and transtracheal jet ventilation as appropriate non-surgical measures and cricothyrodotomy and tracheostomy as the surgical options. Laryngeal mask airway and esophageal-tracheal combitube provide supraglotic ventilation and may not be the best options in our patient with an obstructing supraglotic mass. Trans-tracheal jet ventilation, cricothyrodotomy, and tracheostomy are the best options to bypass the obstruction should successful intubation fail. If a mass is detected after induction, resumption of spontaneous ventilation and flexible fiber optic intubation may offer a safer approach. In an anesthetized parturient where fetal well-being is a concern, awakening the patient may not be a viable option. The most logical approach after failure of appropriate supraglotic maneuvers would be cricothyrodotomy, transtracheal jet ventilation or tracheostomy.


Management of the unanticipated difficult airway has been somewhat standardized by the American Society of Anesthesiology. The decision to utilized general anesthesia in parturients after failed neuraxial block is a difficult one given the four-fold increase in risk of difficult airway. In addition our patient had a pre-existing supraglottic mass that further complicated airway management This case clearly shows the need for advanced airway planning in all parturients.

SOAP 2010