1. Nicole Weiss, MD August 24, 2011

2. Height: Weight: Airway Exam:  Malampatti: III  Thyromental distance: II  Mouth opening: II  Thick Neck, Full Extension

3. Attempt #1: Direct Laryngoscopy  Grade III/IV view; in light of DLT, handed over to staff Attempt #2: Direct Laryngoscopy  37 Fr DLT placed in esophagus Attempt #3: Glidescope  Grade I view  Unable to pass DLT secondary to small mouth opening, difficult angle  Attempted to use eschmann with glidescope, but too flimsy to make curve  Placed a single lumen ETT Attempt #4: Cook Catheter  Placed but unable to slide DLT over  Single lumen ETT placed again Attempt #5: Smaller Cook Catheter  Still unable to pass DLT  Single lumen ETT placed again

4. Decision made to cancel the case  Considered bronchial blocker, univent tube  Safest option to simply stop Plan:  Extubate in a controlled setting & reschedule the case Pt taken to PACU intubated Pt admitted overnight for observation and discharged home the following morning

5. Patient continued to have persistent neck pain Reassured Two days later, still complaining of neck pain with an “expanding mass”, difficulty swallowing Presented to VA Urgent Care CT done…

7. Admitted to the ICU Placed on IV antibiotics ENT took back to the OR for a neck exploration  Found 2cm laceration of the right pillar tract that communicated and had fistulized to the right neck  Right submandibular, parapharyngeal abscess I&D grew out Strep IV antibiotics continued in house Feeding tube placed for patient to be NPO for one week

8. Intubation far most common cause of laryngeal trauma 10% of patients have demonstrable laryngeal pathology one day after short term intubation for surgery Longer term intubation results in laryngotracheal injuries in 90% of patients with long term sequelae in 11% Flint: Cummings Otolaryngology: Head and Neck Surgery, 5th edition

9.  Glidescope or fiberoptic earlier?  Univent tube?  Good for challenging airways  Do not need to be exchanged after the case  Single lumen tube placed first with a cook catheter exchange  May have been successful if done prior to anyway airway trauma