Flexible fibreoptic bronchoscope and the difficult airway: A case report

Abstract

BACKGROUND: Management of the difficult airway will always confront the anaesthetist. This is one area of the practice that the anaesthetist is required to develop divers skills suited for each clinical situation. The ability to use the flexible fibreoptic bronchoscope (FOB) presents the anaesthetist with an addition tool to conduct endotracheal intubation when faced with a difficult airway. OBJECTIVE: To demonstrate the effectiveness of the flexible fibreoptic bronchoscope in the management of the difficult airway. CASE REPORT: A 21-year old male farmer who presented with a 2-year history of a slowly increasing left-sided jaw swelling. The swelling was painless with protrusion into the oral cavity. There was limited mouth opening but no history of trauma. Examination revealed a clinically ill-looking patient who was not in respiratory distress. Interincisor distance was less than 3cm with associated dental anarchy and a large tumour mass in the oral cavity. Cardiorespiratory findings were within normal limits. Radiology revealed translucency of the mandible with multiloculated “soap bubble” appearance. Histology showed typical characteristics of ameloblastoma of the plexiform type. The flexible FOB was checked before the patient was bought into the theatre. An intravenous access was established and a multi-parameter monitor was attached to the patient. Baseline vital signs were within normal limits. Premedication was with intravenous atropine, diazepam and fentanyl. Using a combination of inhalational and airway anaesthesia, with patient breathing spontaneously, flexible FOB was used to effect right nasotracheal intubation with a size 7.0mm cuffed endotracheal tube. The cuff was inflated and the tube secured with adhesive tape. Anaesthesia was augmented with sodium thiopentone and pancuronium bromide was given to achieve muscle relaxation. Left-hemimandibulectomy was done with disarticulation of the left temporomandibular joint. The patient was extubated fully awake after suctioning and reversal of residual relaxation. Postoperative analgesia was with intramuscular pentazocine and diclofenac. The patient was discharged home after ten days. CONCLUSION: The use of the flexible FOB can be very effective in the management of the difficult airway and the modern anaesthetist must strive to acquire the necessary skill needed to use it.

Keywords

• ameloblastoma
• difficult airway
• fibreoptic bronchoscope