Airway Pic-of-the-Week 2014_0825

Kudos to those that responded with answers to the last picture – I hope you found it stimulating!  Jesse Mumba gets the virtual prize (perhaps a sponsor of real prizes will manifest!) for sending in a complete and thorough answer first.  He correctly identified a tracheosophageal fistula on the Gross C (Voit 3B) type, which is the most common (about 86% of cases).  To be fair, it could be the much rarer Gross D, which features a proximal fistula with the oesophagus as well, but this is very unlikely.
The main anaesthetic challenge (other than surgery in a small neonate with a significant chance of other, including cardiac, abnormalities) is the difficult in providing positive pressure ventilation, as the gas flows preferentially into the stomach via the fistula rather than the lungs.  The conventional technique is to maintain spontaneous ventilation through a gas induction until the fistula can be occluded.  We achieved this in the above case by passing a Fogarty balloon catheter into the fistula under vision with a 2mm rigid telescope and then intubating with a 2.5mm ETT.  Significant simultaneous tachycardia and sympathetic stimulation was noted in the anaesthetic personnel, but the infant did very well.
This week’s picture of the week comes with complements of the September edition of Anesthesiology:
Reproduced from Anaesthesiology online (article and image openly accessible by clicking the image above); credit to the authors, dos Reis Falcão et al.
Reproduced from Anaesthesiology online (article and image openly accessible by clicking the image above); credit to the authors, dos Reis Falcão et al.
Transorbital intubation!  Yip, you read that right.  The case report in the September 2014 edition of Anaesthesiology is accessible here and will fill in the details.  Remarkably, this is not the first time this technique has been described in the literature, although prior reports involved the use of a fibreoptic scope rather than direct laryngoscopy.  It goes a long way to illustrate that a good knowledge of the anatomy, technical skill with a wide variety of devices and a flexible approach are the cornerstones of excellence in airway management.
Eye can’t beat that this week…nor will anyone else around the globe.

Airway Pathology Pic-of-the-Week – 2014_0811

I got a good response to a missive sent out via email, so we are trying this again. This is what I sent previously:

Vocal cord papilloma

Numerous people responded correctly. It is indeed a papilloma, which was causing variable obstruction as it swung back and forth through the vocal cords on it’s pedicle. It was managed by videolaryngoscopic intubation with a microlaryngoscopy tube (MLT) followed by surgical debulking by the ENT. Here is a nice simple summary of MLTs and other special ETTs used in ENT surgery, although they erroneously attribute the acronym RAE.  Click here for more about ETTS and to see the correct source.

Pic for this week:

This is a bronchoscopic view from the mid-tracheal level in an infant. Can you tell:
A) What is going on here?
B) Is there a classification system for this pathology, and can you fit this case into it?
C) What is the main challenge and advised technique for dealing with this airway?

Let me know if this is interesting/useful 😉