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A 49-year-old female has been recovering in the postanesthetic care unit (PACU) for the last 4 hours. She has a slowly expanding neck hematoma following an uneventful left carotid endarterectomy under general anesthesia. Subtle neck swelling was noticed shortly after her arrival, and a cooling pressure pack has been placed on the surgical site. One hour earlier, she was noted to have difficulty in swallowing. She has since been noted to have increased respiratory efforts and does not want to lie flat. Vascular surgery has been informed and has booked her for urgent wound exploration and evacuation of hematoma. Her medical history included hypertension and type II diabetes. She is a nonsmoker. She was noted preoperatively to have reassuring airway anatomy. Her prior airway management was documented as easy bag-mask ventilation (BMV) without an oropharyngeal airway (OPA), and a Cormack–Lehane (C/L)1 Grade 1 view with direct laryngoscopy using a Macintosh #4 blade. The trachea was easily intubated with a 7.5-mm internal diameter (ID) endotracheal tube (ETT).

In PACU, she is now sitting upright with a non-rebreathing facemask. Although restless, she is rational and complaining of dyspnea, dysphagia, and neck pain. Her blood pressure is 195/95 mmHg, heart rate is 105 beats per minute, respiratory rate is 28 breaths per minute, and her SpO2 is 94%. She is becoming audibly stridulous. Under a blood-stained dressing, the left side of her neck looks visibly enlarged and discolored. The patient is 5′3″ (164 cm) in height and weighs 172 lb (78 kg). She has adequate vascular access. The OR is being prepared for her return.


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

This is an urgent situation. The patient must be quickly assessed, and decisions made. Although some patients with neck hematomas may be managed with watchful expectancy, case reports attest to the 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 BMV, direct and indirect laryngoscopy, tracheal intubation, use of an extraglottic device (EGD), and open cricothyrotomy, as external landmarks become shifted or indistinct.

Although situational acuity will often preclude diagnostic imaging of the patient presenting with obstructing pathology, if patient cooperation allows, useful information may be obtained by performing nasopharyngoscopy immediately before an attempt at securing the airway....

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