Journal of Clinical Anesthesia (2014) 26, 581585

Correspondence

Difficult airway management in a patient

with combined severe deep neck abscess
and acute epiglottitis with abscess
To the Editor:
The successful use of the Pentax-AWS Airwayscope
(AWS; Hoya, Tokyo, Japan) and a soft-tipped endotracheal tube (ETT) exchanger in the sitting position for a
patient with a severe deep neck abscess with acute epiglottitis is presented.
A 63 year old man was transeferred to the emegergency department for severe respiratory distress. The
patient was unable to maintain a supine position.
Preoperative indirect laryngoscopy showed a severe
deep neck abscess and acute epiglottitis combined with
a bilateral peritonsillar abscess (Fig. 1). To avoid
respiratory collapse, awake intubation was performed
with the patient placed in the sitting position. After 15
minutes of a 0.8 g/kg/hr dexmedetomidine infusion and
topical lidocaine anesthesia at the base of the tongue and
pharynx, the AWS was inserted from the cranial side with
a thin Introck (Pentax) due to difficulty of mouth opening
from the abscess [1]. While carefully avoiding collision
of the AWS with the pharynx, we confirmed the lower
edge of the glottis and inserted a 12-French, soft-tipped
extra firm tube exchange catheter (TE-Soft; Cook
Medical, Bloomington, IN, USA) through the Introck
into the trachea. A spiral tube with a 5 mm internal
diameter was then inserted with the guidance of the
exchange catheter. Successful intubation of the trachea
was achieved without damaging the swollen epiglottis or
bilateral peritonsillar abscess.
This case had all the anatomical aspects of a difficult
airway, ie, severe deep neck abscess combined with acute
epiglottitis [2]. A bronchofiberscope may have worsened
or ruptured the abscess from an unanticipated collision
[3]. By using the soft-tipped exchange catheter and AWS
guidance, it was possible to achieve awake intubation

Conflict of interest and source of funding: None to report.

0952-8180/ 2014 Elsevier Inc. All rights reserved.

Fig. 1 Preoperative laryngoscopic view of the severe glottic swelling

(white arrow) and bilateral peritonsillar abscess (black arrow).

and avoid the worst-case scenario of cannot intubate,

cannot ventilate.
Nobuyasu Komasawa, MD, PhD (Assistant Professor)
Toshiaki Minami, MD, PhD (Professor and Chief)
Department of Anesthesiology, Osaka Medical College
Osaka 569-8686, Japan
E-mail address: ane078@poh.osaka-med.ac.jp
http://dx.doi.org/10.1016/j.jclinane.2014.05.003

References
[1] Asai T, Liu EH, Matsumoto S, et al. Use of the Pentax-AWS in 293
patients with difficult airways. Anesthesiology 2009;110:898-904.
[2] Apfelbaum JL, Hagberg CA, Caplan RA, American Society of
Anesthesiologists Task Force on Management of the Difficult
Airway, et al. Practice guidelines for management of the difficult
airway: an updated report by the American Society of Anesthesiologists
Task Force on Management of the Difficult Airway. Anesthesiology
2013;118:251-70.
[3] Mason RA, Fielder CP. The obstructed airway in head and neck surgery.
Anaesthesia 1999;54:625-8.

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