A Novel Use of Gum Elastic Bougie to Manage an Unanticipated Difficult Airway Due to Vallecular Cyst

Abstract

Sir, Vallecular cysts are rarely seen in the adult population. The peak incidence is in the fifth decade and occurring more frequently in men. Vallecular cysts occur as a result of mucus retention at the base of the tongue. The incidence of vallecular cysts on laryngoscopy is estimated to be between 1 in 1250 and 4200.[1] They can lead to an unanticipated difficult airway with serious ramifications if the patient requires rapid sequence induction (RSI). We are reporting a case of unanticipated difficult intubation in a 56-year-old male with asymptomatic vallecular cyst listed for emergency exploratory laparotomy for acute intestinal obstruction. The patient's preanesthetic check-up (history and general examination found no medical risk factor and no history of any problem due to this incidental find vallecular cyst) and routine blood investigations, electrocardiogram, chest X-ray were unremarkable. General anesthesia after RSI with cuffed endotracheal tube was planned. The patient was preoxygenated with four vital capacity breaths, and routine RSI protocol was followed. Induction of anesthesia was done with midazolam 1 mg, fentanyl 100 μg, thiopentone 200 mg, and muscle relaxation was achieved with succinylcholine 100 mg. Direct laryngoscopy revealed a cystic pedunculated mass measuring approximately 40 mm × 30 mm in the vallecular region and was obscuring our glottic vision. Keeping in mind the “full stomach” scenario, we used a gum elastic bougie (GEB) to displace the cyst and introduced it in the trachea. An 8.0 mm sized polyvinyl chloride endotracheal tube was railroaded over the GEB into the trachea, and the airway was secured. The patient was ventilated with a mixture of oxygen, air, and sevoflurane, using FiO2 of 0.5. An urgent ENT consultation was sought after intubation. The ENT surgeon confirmed it to be a vallecular cyst and advised aspiration of the cyst. A volume of 15 ml of clear fluid was aspirated leading to its collapse. The patient was re-evaluated at the end of the surgery for any re-accumulation which was found to be negative. We could thus, safely extubate the patient. On reviewing the literature, it was observed that no specific technique has been clearly earmarked for such a scenario. Techniques, such as paraglossal laryngoscopy, awake fiberoptic bronchoscopy, inhalation induction, styletted endotracheal tube, endotracheal tube railroaded over the suction catheter, rigid laryngoscope, and even intubation after muscle relaxation and cyst aspiration had been attempted, but the majority of patients were known cases of vallecular cyst since preoperative and none required RSI.[2 3 4] The site and nature of the cyst obviate the use of supraglottic airway devices. Moreover, as these devices are inserted blindly into the airway, they might rupture the cyst leading to bleeding and aspiration. With the experience of managing this case, it can be suggested that when faced with unanticipated difficult airway owing to undiagnosed vallecular cyst with a patient requiring RSI, instead of going for a preintubation aspiration of the cyst to secure the airway, a GEB-guided endotracheal intubation using a conventional laryngoscope, is a much safer option. Keeping in mind that there is still limited availability of fiberoptic bronchoscope and video-laryngoscope at many places that may offer added benefit, a GEB could be considered as an initial airway adjunct of choice to displace the cyst and secure the airway in known cases of vallecular cyst or when faced with similar scenario in emergent or nonoperating room environment. This case management depicts one of the new off-track uses of usually available GEB in any operation theater. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.