Parotid Abscess with Threatened Airway Obstruction- A Case Report Dr Subramania Bharathiar –Prof and HOD, Dr Ponambalam, Dr Lakshmi, Dr Bhaskar Dr Jyoti P Rasalkar Stanley Medical College, Chennai

Chief complaints 40 yr/male C/o painful swelling below left ear and left cheek since 3 days.

History of Presenting Illness Patient complained of swelling over left cheek and below the left ear of 3 days duration; gradually progressing in size associated with deviation of mouth to opposite side

 Swelling associated with throbbing pain  h/o high grade fever (+)  h/o not able to eat/drink/speak  h/o pus draining from mouth

Past history  No h/o HTN/DM/IHD/BA/TB/Epilepsy/drug allergy  No h/o previous surgeries  h/o smoking(+), alcoholism(+)

Investigations  Hb - 11 gm %  TC – 20,000/cumm  RBS – 102 mg/dl  Blood urea – 24 mg/dl  Serum creatinine – 1.2 mg/dl  Chest X-Ray – normal study  ECG – Sinus Tachycardia

 Neck X-Ray AP: large soft tissue shadow below left ear  CT Scan Head and Neck: large hypodense lesion with irregular ring enhancement involving superficial and deep lobes of parotid significant edema of surounding tissues causing indentation of lateral pharngeal and oral mucosa into oropharyx and oral cavity

Clinical examination  Patient conscious, oriented  Temperature-102 degree F  PR -124/min  R/R:28/min  BP-110/70 mm hg  SpO2-97%(room air)  CVS-S1 S2 (+) no murmurs  RS- NVBS (+) no added sounds

Local examination  A huge left parotid abscess extending from back of left ear to angle of mouth  From lower margin of left eyelid to lower part of neck  Pus draining out of the mouth

Airway examination  Mouth deviated to right,  Severe trismus with restricted mouth opening (inter-incisor gap:2cm) and pus draining out of the mouth  Short neck with restricted extention. Swelling extending into left side of neck, causing neck edema.  No signs of chest retraction or stridor

 Case was posted for emergency Incision and Drainage of the abscess  Case was assessed under ASA PS III(E) (Sepsis).

Anaesthetic plan  Tracheostomy under local anaesthesia with portex cuffed tracheostomy tube  Genaral anaesthesia with controlled ventilation

 I V access left forearm with 18 G IV cannula  Monitor HR, NIBP, SPO2, ECG  Patient put in supine position with 15 degree head up tilt  Tracheostomy performed by ENT Surgeon under local anaesthesia with 7.5mm Portex cuffed tracheostomy tube

 Premedication: inj.glyco 0.2 mg i.v+ inj.fentanyl 100 mcg i.v  Preoxygenation: 100% O2 -3min  Induction: – inj.thiopentone 250 mg  Maintainance: N2O:O2:4:2 +inj.atracurium 25mg +halothane %

Intra-Op..  Procedure: Incision and drainage of abscess  200 ml pus drained  Duration of surgery: 20 min  I V fluids: 2 pint crystalloids  HR: / min  BP: 130/ /90 mm hg  SpO2: 97%-98%

After onset of spontaneous respiration, patient was reversed with inj.neostigmine 2.5 mg i.v + inj.glyco 0.4 mg i.v

 Patient concious, oriented, obeys command.  Reflexes regained; muscle power adequate  PR:110/min  BP:120/80 mm Hg  SpO2: 99% on room air  CVS: S1S2 (+)  RS: NVBS (+) Tracheostomy tube was removed after 7 days Post-operatively,

Discussion

Problems 1) Severe trismus 2) Protrusion of abscess into the airway 3) Facial deformity (edema) 4) An inflamed and reactive airway

 Parotid abscess often presents with severe trismus with mouth opening inadequate for intubation  The abscess itself by protruding into the airway can result in obstruction  Inflammation and edema of the surrounding tissues contributes to airway obstruction as also facial deformity Parotid Abscesses And Anaesthetic Challenges

 Good mask seal often not possible and may not be adequate for positive pressure ventilation  Any rupture of abscess can lead to fatal aspiration  If succinylcholine is administered to break the trismus, consequent relaxation of pharyngeal muscles may lead to upper airway obstruction

 Any loss of consciousness or interference with airway reflexes could result in airway obstruction or aspiration  Laryngospasm is almost always a possibility in these reactive airways  Nasogastric tube placement risky for the same reasons

The Action Plan  In this situation, an emergency tracheotomy is life saving.  Induction should be delayed until airway has been secured (often) with a tracheostomy.

Tracheostomy  Surgical airway  Time required- 3 min  It is indicated when the risk of loss of the airway during attemped tracheal intubation is high

Tracheostomy under local anaesthesia is an excellent way to secure airway in following situations: 1)patient with an upper airway swellings with a distorted pathway for endotracheal intubation 2)patient with a bulky friable mass in upper airway

In these situations, attempts at direct laryngoscopy and intubation may result in rupture and/or aspiration of pus, blood or material from a friable mass

Alternative Plans  Fiberoptic oro/nasotracheal intubation under topical anaesthesia  Surgeon can attempt needle aspiration for decompression of abscess under LA

Awake Fiberoptic Intubation Considered as Gold-Standard in conditions of difficult airway  Spontaneous breathing continues  Oxygenation and ventilation maintained  Intubation easier  Anatomy and muscle tone preserved  Phonation as a guide

Disadvantages  Skill and expertise needed  Advancement of ETT into trachea may pull the FOB out of trachea  Forceful advancement should be avoided because it may traumatise the larynx  Vision obscured by secretions or blood and interfere with airway evaluation and endotracheal intubation

Contraindications to FOB 1.Lack of adequate time 2.Edema of pharynx or tongue, tracking infection, inflammation and hematoma (reduced field of vision) 3.Blood/secretions in oral cavity 4.Pharyngeal abscess (risk of rupture while railroading of ETT)

Summary Inflammatory masses around upper airway throw a combination of a variety of anaesthetic challenges and securing an airway safely is the cornerstone of management