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CASE PRESENTATION

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A 60-year-old male has been in the post-anesthetic care unit (PACU) for 6 hours with a slowly expanding neck hematoma following an uneventful left carotid endarterectomy under general anesthesia. Over the last 45 minutes he has started to complain of difficulty with his breathing. Neurosurgery has booked him to return to the operating room (OR) for wound exploration and evacuation of hematoma. He is a smoker, takes medications for hypertension, hyperlipidemia, and type 2 diabetes mellitus, and was noted preoperatively to have reassuring airway anatomy. Post-induction at the original surgery, he was documented to have been easy to ventilate using a bag-mask, presented a Cormack–Lehane (C/L)1 Grade 1 view at direct laryngoscopy using a Macintosh #4 blade, and the trachea was easily intubated with an 8.0-mm internal diameter (ID) endotracheal tube (ETT).

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In the PACU he is now sitting upright, breathing oxygen at 10 L·min−1 via a non-rebreathing facemask. Although restless, he is rational, complaining of dyspnea, dysphagia, and neck pain. Blood pressure is 180/95 mm Hg, heart rate 100 beats per minute, respiratory rate 30 breaths per minute, and his SpO2 is 95%. He is audibly stridulous. Under a blood-stained dressing, the left side of his neck looks visibly enlarged and discolored. The patient is 5′10″ (178 cm) in height and he weighs 230 lb (105 kg). He has vascular access. An OR is being prepared for his return.

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PATIENT EVALUATION AND MANAGEMENT OPTIONS

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In What Ways Might This Patient Present Difficulty with Airway Management? What Are Key Aspects of the Airway Examination in This Situation?

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This is an urgent situation. The patient must be quickly assessed and decisions made. Although some patients with neck hematomas are simply observed, case reports attest to difficulty in predicting if or when these individuals will go on to sudden and catastrophic airway obstruction.2-4 As part of the patient's evaluation, a formal airway examination should be performed, seeking predictors of difficulty in all aspects of airway management.5 Even though the patient's anatomy presented no difficulty with airway management earlier that day, the presence of a neck hematoma changes everything. With evidence of obstructing pathology in the airway as manifested by stridor, neck swelling, and the patient's dyspnea and agitation, difficulty can now be anticipated with all of bag-mask-ventilation (BMV), direct and indirect laryngoscopy and tracheal intubation, use of an extraglottic device (EGD) and potentially, even open cricothyrotomy as external landmarks become shifted or indistinct.

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As situation acuity will often not permit diagnostic imaging of the patient presenting with obstructing pathology, if patient cooperation allows, useful information may be obtained by performing nasopharyngoscopy immediately before attempts at securing the airway.6,7 This is generally well tolerated, and can provide information about any lateral displacement of the larynx, the degree of perilaryngeal edema, or location and size of an obstructing ...

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