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Journal of Clinical Anesthesia (2016) 34, 314317

Journal of Clinical Anesthesia (2016) 34 , 314 – 317 Case Report Transorbital endotracheal intubation: a

Case Report

Transorbital endotracheal intubation:

a nonstandard approach to a difcult airway , ,

to a dif fi cult airway ☆ , ☆ ☆ , ★ Nathan H. Waldron MD

Nathan H. Waldron MD (Resident)

Michael P. Ogilvie MD (Fellow, Plastic Surgery) b , David B. Powers MD, DMD, FACS, FRCS (Ed) (Associate Professor of Surgery; Director, Duke Craniomaxillofacial Trauma Program) b , Michael R. Shaughnessy MD (Assistant Professor) a


, Bryant W. Stolp MD, PhD (Assistant Professor) a ,

a Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA b Department of Surgery, Duke University Medical Center, Durham, NC, USA

Received 2 February 2016; revised 8 April 2016; accepted 2 May 2016


Airway management issues; ENT surgery; Fiberoptic intubation; Oral surgery; Critical care issues; Education in anesthesia

Abstract We present the case report of a 49-year-old gentleman with a history of adenoid cystic carcinoma of the left nare status post curative bifrontal craniotomy, left lateral rhinotomy and medial maxillectomy, adjuvant radiotherapy, and orbital exenteration for optic neuropathy, complicated by medial wall dehiscence. His course was also complicated by severe radiation trismus, for which he was scheduled to undergo bilateral mandibular coronoidectomies. Given his limited mouth opening, the surgeon requested a nasal endotracheal tube. Because of concerns of traumatizing his nare, we utilized a exible beroptic bronchoscope to perform asleep transorbital intubation. Airway management in patients with severe trismus may require ingenuity. © 2016 Elsevier Inc. All rights reserved.

1. Introduction

Trismus is a known adverse sequelae of radiation therapy for head and neck malignancies that signicantly reduces qual- ity of life [1] . Arising from radiation-induced brosis of the

Conicts: All authors reported no conicts of interest. Attestation: All authors approved the nal manuscript.

Funding: This study was funded with departmental funds. N.H.W. is sup-

ported by a Foundation for Anesthesia Education and Research fellowship grant.

Corresponding author at: Department of Anesthesiology, Duke Universi- ty, DUMC 3094, Durham, NC 27710, USA. Tel.: +1 919 724 5217; fax: +1 919 681 7893. E-mail addresses:, (N.H. Waldron), (B.W. Stolp), (M. Ogilvie), (D.B. Powers), (M.R. Shaughnessy).

0952-8180/© 2016 Elsevier Inc. All rights reserved.

muscles of mastication, trismus may be treated with exercise therapy utilizing jaw-mobilizing devices to increase mouth opening [2]. Unfortunately, radiation trismus may be refracto- ry to exercise therapy [3] and require surgical procedures (mandibular coronoidectomies) to increase mouth opening [4]. Patients with severe trismus present a challenge for airway management. We present a novel airway management strategy for a gentleman with severe trismus related to radiation brosis presenting for bilateral coronoidectomies. The patient detailed below has given written permission for a case report detailing his anesthetic management to be published.

1.1. Case description

We describe a 49-year-old patient with a history of T3 N0 cystic adenoid carcinoma of the left nare, diagnosed in 2008.

Transorbital endotracheal intubation


He underwent a bifrontal craniotomy, left lateral rhinotomy, and medial maxillectomy in 2008. He also underwent adjuvant radiation therapy of 60 Gy treated from November to Decem-

ber 2008. In 2010, he experienced 2 recurrences, both treated

with wide local excision. In addition, he had malignant peri-

neural invasion of the trigeminal distribution of V2 in 2012, which was treated with proton beam therapy.

Unfortunately, he experienced deteriorating vision in his left eye as a result of radiation and underwent a left orbital ex- enteration in 2013. This procedure was complicated by a me-


wall dehiscence, leaving him with a persistent 8- to 9 -


communication between his orbit and oropharynx, for

which he wore an oral prosthesis. Also as a result of his radia-

tion, he experienced severe trismus with an oral opening of

5 mm, which precluded rigorous dental hygiene and had re- sulted in dental caries. He presented to the operating room for bilateral mandibular coronoidectomies. Because of inade- quate available space at the operative site, the attending sur- geon requested a nasal intubation. The patient had obvious radiation brosis of the left nare, and also reported symptoms of nasal obstruction in the contra- lateral (right) nare, raising suspicion for radiation damage. Oc- clusion of the left (radiated) nare and forceful inspiration produced minimal airow through the right (nonradiated) na- re, but brisk air movement through the left facial defect. Of note, the patient was quite tall (203 cm), potentially requiring

a long nasal RAE tube for intubation. After discussion with the

patient, we agreed upon attempting transorbital intubation to avoid traumatizing his patent nostril. Of note, the patient had been easy to mask ventilate (after occluding the facial defect)

during a recent anesthetic at our institution. Additional medical history was notable for peripheral neuropathy due to chemother- apy and chronic oral pain on tapentadol 250 mg twice daily. The patient was premedicated with 2 mg of midazolam pri- or to arrival in the operating room. With patient permission, we placed an 100-mL bag of normal saline over the facial de-

fect and commenced standard preoxygenation. Capnography

and measurement of end-tidal oxygen both showed satisfacto- ry air movement with this method. Anesthesia was induced


lidocaine, fentanyl, and propofol. Mask ventilation was


with the 100-mL bag of normal saline covering the facial

defect. After administration of neuromuscular blockade, a

exible beroptic scope (exible intubation video endoscope, 4.0 mm × 65 cm, manufactured by Karl Storz Endoscopy)

was advanced into the orbital cavity. After navigating through

a pathway of inamed tissue, past inferior turbinates, into the

oropharynx, and then through the glottis, a 6.0 microlaryngeal


(Mallinckrodt Hi-Lo Oral/Nasal cuffed tracheal tube, 8.2-


outer diameter, 28.5-cm length; Covidien) was gently ad-

vanced atraumatically past the cords ( Figs. 1 and 2). Careful inspection of the entire stula tract after ETT placement re- vealed no evidence of bleeding from the friable tissues. The case proceeded uneventfully, with successful coronoidec- tomies improving oral opening from 5 to 40 mm. The patient

was extubated at the end of surgery and discharged home on postoperative day 1.

2. Discussion

In this report, we detail a novel airway management tech- nique for a patient with severe radiation trismus undergoing bi- lateral coronoidectomies. Trismus, dened as a mouth opening b 35 mm, is estimated to affect between 5% and 38% of head and neck cancer patients, although estimates vary signicantly [5]. Exercise therapy may benecial to increase mouth open- ing, and thereby functionality, in radiation trismus [6]. Unfor- tunately, conservative therapy may fail, necessitating surgical intervention. In a prospective case series of 18 patients with ra- diation trismus who had failed conservative therapy, all pa- tients had an increase in mouth opening 20 mm after coronoidectomy. In addition, all patients maintained an inter- incisal distance 35 mm for at least 6 months [7], indicating that coronoidectomy generally gives durable bene t to pa- tients with refractory radiation trismus. Patients with radiation trismus present a signicant airway management challenge for anesthesiologists. Although there is no formal minimum mouth opening required for laryngosco- py, 20 mm has been proposed as a reasonable threshold [8]. In patients with extremely limited mouth opening requiring endotracheal intubation, nasal intubation may be a suitable al- ternative. However, patients receiving radiotherapy for naso- pharyngeal carcinoma have a 32% incidence of sinonasal complications (including choanal stenosis, chronic sinusitis, osteoradionecrosis, and/or nasal synechiae), potentially com- plicating nasal intubation [9]. When nasal intubation is unsuit- able and tracheostomy undesirable, retromolar intubation is a potential option for securing the airway [10]. Unfortunately, intraoral surgery precluded retromolar intubation in our pa- tient. As such, we chose to explore alternative options for en- dotracheal intubation prior to risking nasal/sinus trauma or entertaining tracheostomy. Our patient's unique anatomy made transorbital intubation feasible. Orbital-nasal and orbital-sinus connections are a known complication of orbital exenteration [11] . Oro-antral stulas, or unnatural communications between the maxillary sinus and the oral cavity, can arise from a diverse set of cir- cumstances, including trauma, tumors, maxillary pathology, or most commonly from extraction of the rst and second maxillary molars [12]. Together, our patient had a patent tract traversing the medial orbital wall, maxillary sinus, and oro- pharynx prior to arriving in the hypoglottic region. There are limited prior reports of transorbital intubation in the literature [13 17] . In 2 prior reports, a laryngoscope was used either through the orbital defect [13] or orally [17] to visualize the glottis. An alternative strategy for patients with small orbital defects is to use a beroptic bronchoscope, as we did in our case. In the 2 previous reports of beroptic transorbital intuba- tion [14,15], the orbit was topicalized, the patients were sedat- ed, and spontaneous breathing was maintained throughout intubation. In our case, we chose to induce general anesthesia prior to any airway manipulation because we had the benet of a recent anesthetic record with clear documentation that our patient was easy to mask ventilate. Our comprehensive


N.H. Waldron et al.

316 N.H. Waldron et al. Fig. 1 Side pro fi le of transorbital endotracheal tube placement.

Fig. 1 Side prole of transorbital endotracheal tube placement. Im- age also serves to display patient's maximal preoperative mouth opening (interincisal distance of 5 mm).

preoperative discussion with the patient covered risks of transor- bital intubation, including bleeding, as well as potential backup plans, including inability to perform intubation and resultant emergence from anesthesia, or emergency tracheostomy.

emergence from anesthesia, or emergency tracheostomy. Fig. 2 Head-on view of transorbital endotracheal tube

Fig. 2 Head-on view of transorbital endotracheal tube placement. Also note obvious radiation brosis of the left nare, with radiation changes on the right aspect of the nose, as well.

Our report adds to the current body of literature detailing novel airway management strategies for patients with severe trismus. Key components of our plan were ensuring adequate mask ventilation after occluding the orbit and the use of a microlaryngeal endotracheal tube in order to minimize orbit- al/sinus trauma. Our solution allowed us to minimize risk of epistaxis and damage to the patient's contralateral nare, while also avoiding potential complications of tracheostomy. In ad- dition, a thorough preoperative examination and conversation with our patient regarding the relative merits of transorbital vs nasal intubation vs tracheostomy was important. Although transorbital intubation may seem morbid, our strategy allowed us to spare our patient potential complications of nasal intuba- tion [18]. Anesthesiologists caring for patients with complex head and neck anatomy are encouraged to consider novel tech- niques for securing the airway when it might provide patient benet or minimize potential harm.