Comparison of the C-Mac video laryngoscope with the McGrath Series 5 video laryngoscope concerning an extremely difficult airway.

A 51-year-old patient was admitted to the University Hospital for middle ear surgery. Six years earlier the patient had undergone a thyroidectomy due to cancer, followed by radiation therapy to the neck area. Potential difficult intubation associated with post-radiation lesions was tested and revealed a mouth opening of approximately 2 cm, reduced neck mobility and highly positioned larynx resisting movements. As airway manipulations under local anaesthesia were poorly tolerated by the patient, inhalation anaesthesia with sevoflurane was provided with spontaneous breathing preserved [1]. Due to the small mouth opening, the attending anaesthetist attempted to use the TotalTack video laryngoscope (Medcomflow, Barcelona, Spain). Unfortunately, the attempt failed because of very restricted mouth opening (Fig. 1). It was decided to use the McGrath Series 5 instead (Aircraft Medical, UK). Although the blade was successfully placed in the mouth, only the epiglottis was visualized (Fig. 2). Due to postradiation lesions, the larynx was immobilized and the pressure exerted on the organ did not improve the vision visiualisation of entrance to larynx. A decision was then made to use the C-Mac D-blade video laryngoscope (Storz, Germany) and the laryngeal aperture was visualized (Fig. 3). Unfortunately, the laryngeal lumen was found to be considerably narrowed by neoplastic proliferation. The Frova introducer (Cook, Great Britain) was inserted into the larynx, ensuring ventilation through its lumen, and jet ventilation was applied using a Ventrain ventilation device (Dolphys Medical, Eindhoven, Holland). At the same time tracheotomy was started, which, however, was extremely difficult due to technical problems — postradiation lesions. Indeed, an experienced laryngologist had serious problems identifying the trachea. The anaesthesiologist performed a tracheal puncture, inserted the introducer and a (surgical) tracheotomy was performed. After restoration of airway patency and consultations with surgeons, it was decided to postpone the procedure and the patient was admitted to the intensive care unit for observation and diagnosis of neoplastic proliferation of the larynx. A chest x-ray revealed pneumothorax on the left side, which was secured. Moreover, an ultrasound of the larynx was performed which revealed a larynx with proliferating cells (Fig. 4). Patients with potentially difficult airways should have them secured using awake intubation or pre-operative tracheotomy under local anaesthesia. However, if a patient does not tolerate airway manipulations under local anaesFigure 1. Attempt to introduce TotalTrack in the patient’s mouth