At a recent joint conference between the Department of Otorhinolarygnology Head and Neck Surgery and the Department of Anesthesiology and Critical Care, UPENN there was a discussion of the appropriate management of patients with laryngeal or glottic injuries. The risks of intubation before proper evaluation of the injury were emphasized. These injuries require joint evaluation and decision making by the otorhinolaryngologist and the anesthesiologist. Attempts at intubation whether by direct laryngoscopy or fiberoptic bronchoscopy can lead to irreparable damage or even separation of the trachea from the larynx. Suspension laryngoscopy under total intravenous anesthesia with jet ventilation through a small cannula may be the best intervention, but only in cases where there is adequate airway visualization and expertise available. In all other circumstances a tracheostomy without prior intubation is safest. Fiberoptic bronchcoscopy does not allow visualization of the glottis or larynx while the tracheal tube is being passed. There is some data suggesting that laryngeal injury after fiberoptic intubation is more frequent than injury after intubation using direct laryngoscopy (Maktabi MA et al: Assessment of acute laryngeal injury following awake fiberoptic vs. routine endotracheal intubation. ASA Annual Meeting abstract A-1595, 2004). In the pediatric population a mask induction may be the most appropriate approach even in the presence of a full stomach. For a review of the anesthetic management of laryngeal injuries see: Bhojani RA et al: Contemporary assessment of laryngotracheal trauma. J Thor Cardiovasc Surg 2005;130:426-32.
David S. Smith, M.D., Ph.D.
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