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Extensive Lymphadenopathy Complicating Airway Management in a Parturient
Abstract Number: S 68
Abstract Type: Case Report/Case Series
Introduction: This case report of a parturient presenting with neck swelling concerning for difficult airway emphasizes the need for a multidisciplinary approach to care.
Case: A 25-year-old G3P2 patient at 35+6 weeks gestational age (GA) presented to our institution with “tennis ball sized” neck swelling and voice change. The patient denied dysphagia or dyspnea in the supine position with uterine displacement. Body mass index was 37. Interincisor distance was 2cm, limiting Mallampati determination. Neck extension was limited by pain, and no tracheal deviation was present. Computed tomography [Fig1] showed extensive submandibular, supraclavicular, and mediastinal lymphadenopathy without airway compression. The ENT service performed fine needle aspiration, consistent with carcinoma, and bedside fiberoptic nasopharyngoscopy, showing no airway abnormality. Inflammatory breast cancer was suspected based on breast ultrasound, with punch biopsy results pending.
At 37+1 GA, the patient was taken for primary Cesarean delivery for breech presentation under neuraxial anesthesia after discussion with surgical oncology, ENT, radiology, anesthesia, and obstetric services, with plans for additional surgery and treatment of carcinoma after the immediate postpartum period. The patient received low-dose combined spinal (0.4 ml of 0.75% hyperbaric bupivacaine with 100mcg morphine and 15mcg fentanyl) epidural with fiberoptic bronchoscope and airway cart present for the entirety of case. After titration of epidural with 2% lidocaine with epinephrine, the patient had adequate sensory level for surgery and uneventful delivery.
Discussion: Initial plans for this patient were for awake fiberoptic intubation and general anesthesia for Cesarean delivery. Regional anesthesia does not represent a solution to the parturient with a difficult airway, and strategy for intubation must be determined(1). After further imaging and ENT evaluation, however, it was clear that she had no airway compromise and that her voice change was due nerve involvement, not direct compression. There was multidisciplinary coordination of care prior to delivery and continuous adjustment of anesthetic plan based on evolving information. Neuraxial anesthesia was ultimately selected due to reassuring airway elements and the ability to convert to general anesthesia intraoperatively if necessary.
Reference: 1.ASA Task Force of Management of the Difficult Airway.Anesthesiol 2003:1269-77