Videolaryngoscopy to aid transoesophageal echocardiography probe insertion

Transoesophageal echocardiography (TOE) carries a risk of oesophageal and pharyngeal trauma, particularly in the setting of previous instrumentation or surgery.^1,2 We describe the novel use of videolaryngoscopy to assist during the placement of a TOE probe in a patient with a difficult airway.

A 60-year-old man (American Society of Anesthesiologists class 3) attended for semi-urgent TOE-guided direct current cardioversion (DCCV) for new-onset atrial flutter. Past medical history was notable for mandibular alveolar squamous cell carcinoma (SCC; cT4aN1Mx) two years earlier, with wide local excision of the mandibular alveolar SCC, segmental mandibulectomy, bilateral neck dissection, surgical tracheostomy and fibular free flap reconstruction. Postoperative flap bleeding and wound dehiscence had required further left turnover pectoralis major flap, and he had also received radiotherapy and hyperbaric oxygen therapy. External examination revealed significant scarring and ‘woodiness’ at the submandibular and neck areas, consistent with post-radiotherapy changes. He was edentulous with trismus and had a Mallampati score of 3.

The procedure was conducted in the left lateral position, with supplemental oxygen by way of a disposable mouthguard and a nasal cannula, with a carbon dioxide line (Meditech Systems Ltd., Dorset, UK). General anaesthesia was induced with intravenous midazolam 1.5 mg intravenously and a propofol infusion. Several attempts by a highly experienced imaging cardiologist to intubate the oesophagus with the transducer (X8-2t; Philips Healthcare, Amsterdam, The Netherlands) were unsuccessful, and furthermore were complicated by severe hypoxia consistent with trauma-induced laryngospasm. Airway management with bag–mask ventilation and then suxamethonium administration successfully restored oxygenation, but the team contemplated abandoning the procedure despite an ongoing strong indication. However, pharyngeal visualisation was achieved with the introduction of a C-MAC videolaryngoscope (Karl Storz, Australia) with a D-blade into the pharynx. The upper oesophagus was noted to be laterally displaced, accounting for the difficulties with blind intubation; however, insertion of the transducer was now readily achieved at the first attempt under real-time direct visualisation. Echocardiographic assessment of the left atrial appendage confirmed the absence of any intracardiac thrombus. However, prior to completion the procedure was complicated by significant upper airway obstruction, resulting in major and repeated oxygen desaturation requiring ongoing airway management, dexamethasone and videobronchoscopy. However, it was possible to proceed to DCCV after airway stabilisation, with restoration of sinus rhythm. The patient was observed in the intensive care unit overnight, and discharged home the following day. At a follow-up interview, the patient gave permission for publication of this episode of care.

This report details the utility of videolaryngoscopy in those cases in which blind oesophageal intubation proves difficult or prohibitive, in which abandonment of the procedure might otherwise be necessary. Ready access to videolaryngoscopy in transoesophageal echocardiography departments and attendant training in its use may thus be desirable, particularly for high-volume units. Second, videolaryngoscopy is likely to ameliorate the risk of oesophageal trauma, perforation and airway complications in those in whom there are pre-existing risk factors. Indeed, a more routine use of this approach may be particularly desirable in those with prior head and neck surgery and radiotherapy, in whom the risks of oesophageal trauma or perforation are amplified. Third, when airway complications such as laryngospasm (which carries a significant risk of morbidity and warrants urgent airway management) do occur, physician certainty that the transducer had correctly entered the oesophagus allows more rapid evaluation and targeted treatment.

While this is the first report of the use of D-blade-assisted videolaryngoscopy, there are other reports detailing the potential role of direct visualisation. Hirabayashi first described the use of a Glidescope (Verathon Inc., Bothell, WA, USA) videolaryngoscope to aid the insertion of a TOE probe when blind insertion, head repositioning and even the use of a Macintosh laryngoscope, had failed. ³ Kitagawa and colleagues reported the use of an Airway Scope (Pentax, Tokyo, Japan) to facilitate the passage of a TOE probe when standard manipulation of the head and neck had failed. ⁴ Hirabayashi et al. have described their institution’s experience with an Airtraq (Prodol Meditec, Vizcaya, Spain) optical laryngoscope and have suggested that this device may be useful whenever difficulties are encountered. ⁵ These publications thus support the assertion of the current report, which is that videolaryngoscopy should be more routinely considered in those patients with high-risk features for either oesophageal anatomy or airway difficulty.