Case reportAcute upper airway obstruction secondary to late presentation of a massive oropharyngeal arteriovenous malformation
Introduction
Management of the partially obstructed airway poses one of the most difficult dilemmas facing today's anesthesiologist. The strategies available in this situation were expertly summarized by Mason and Fielder in their editorial in Anaesthesia in 1999 [1]. For the patient with airway obstruction in and around the larynx presenting with stridor at rest, they recommend either inhalational induction or a tracheostomy with local anesthesia. However, in some clinical scenarios these options are simply not possible.
A 65 year-old patient with a massive oropharyngeal arteriovenous (AV) malformation presented with an acute cerebrovascular accident (CVA), reduced consciousness, and stridor. The airway was secured using a fiberoptic bronchoscope without any sedation.
Section snippets
Case report
A 65 year-old man presented with right-sided hemiparesis and a reduced Glasgow Coma Scale (GCS) score of 11/15 (E3, M5, V3). He had a congenital AV malformation for which he had apparently never sought medical intervention, and a past medical history of a right frontal lobe infarct 17 years ago, from which he had made a complete recovery, and a myocardial infarction 11 years previously. His medications included bisoprolol, lisinopril, and aspirin.
The anesthesiologist was asked to evaluate the
Discussion
In those with AV malformations of the face, in whom intubation is considered possible, the initial plan involves an inhalational technique with an attempted intubation. The backup plan involves a tracheostomy by an ENT surgeon who should be gowned and gloved during the inhalation induction.
These principles may be applied in the majority of cases of upper airway obstruction in adults. However, there are no strict recommendations when it comes to management of a difficult airway in the acute
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