ANESTHESIOLOGISTS are faced with myriad surgical procedures designed to alleviate sleep-disordered breathing in patients with obstructive sleep apnea (OSA). The main concern in caring for these patients is the potential difficult airway in many of these patients and also the comorbidities caused by OSA. We report a case of immediate postoperative airway obstruction that necessitated emergency cricothyrotomy after performance of a relatively new procedure called tongue suspension or tongue base surgery. 1
The patient is a 48-yr-old man who presented to the operating room for tongue suspension for OSA. The patient underwent laser surgery 6 weeks previously to reduce redundant pharyngeal tissues. This was accomplished without improvement of his symptoms.
The patient had used a continuous positive airway pressure mask at home without relief of symptoms. The patient had a history of hypertension and gastroesophageal reflux disease (GERD). He weighed 155 kg and was 70 in tall. Airway examination consisted of a Mallampati I, which showed good range of motion of his cervical spine and adequate thyromental distance. The patient was taken to the operating room, and standard monitors were applied. In the operating room, 2 mg midazolam was administered to the patient in 1-mg aliquots. His right naris was anesthetized with 4 ml cocaine, 4%. Then, an induction of 150 mg propofol was administered, followed by 140 mg succinylcholine. A 7.0 wire-reinforced tube was passed easily through the right naris, but the vocal cords could not be identified using a Macintosh No. 3 blade. Oxygen saturation decreased to 90%, and mask ventilation with jaw thrust and an oral airway was difficult to perform. A Miller No. 3 was inserted into his mouth and a grade 1 visualization of the vocal cords was achieved. An 8.0 endotracheal tube was passed through his mouth and then past the vocal cords. At the request of the surgeon, the wire-reinforced tube was reinserted into the right naris and passed through the vocal cords as the 8.0 endotracheal tube was removed.
Afterward, the patient underwent tongue suspension surgery. The surgery was uneventful. At the conclusion of surgery, administration of the anesthetic agent (isoflurane) was discontinued. The patient was returned to spontaneous ventilation, and then was reversed with neostigmine and glycopyrolate. Negative inspiratory force of the patient was greater than 40 cm H2O, tidal volume was greater than 500 ml, sustained head lift lasted 5 s, and the patient followed commands. The patient was then extubated. He was able to take three breaths in which stridor was heard and then complete airway occlusion occurred. The patient could not undergo ventilation via mask with an oral airway or by two-handed mask ventilation. Oral intubation was impossible because of redundant and swollen oropharyngeal tissues. A No. 4 laryngeal mask airway was introduced into the patient’s mouth, through which assisted ventilation was possible but difficult. Oxygen saturation was maintained in the low 80 range. The decision was made to perform emergency cricothyrotomy. Subsequent direct laryngoscopy showed a markedly swollen epiglottis and grossly edematous laryngeal and hypopharnygeal tissue.
Postoperative radiography was consistent with pulmonary edema secondary to negative-pressure pulmonary edema. Initial blood gas at 100% oxygen showed a partial pressure of arterial oxygen (Pao2) of 78, which, with 10 cm positive end expiratory pressure, increased to a Pao2 of 91 at 60% oxygen. Oxygenation improved the next morning; Pao2 was 106 at 40% oxygen.
Two days later, the patient was brought to the operating room for direct laryngoscopy and possible oral intubation. The examination showed a markedly swollen epiglottis and redundant supraglottic tissues. The vocal cords were not viewable. The decision was made to perform tracheostomy with cricothyrotomy. Hospital course was uneventful and the patient was discharged on the eighth postoperative day. Two weeks later, the tracheostomy was closed. Significant subjective improvement was seen in the sleep apnea, and the patient no longer required the use of a continuous positive airway pressure mask.
Surgical correction of OSA using uvulopalatopharyngoplasty has shown a high failure rate. 2
Several surgical techniques are available for the treatment of OSA that are directed at relieving the tongue base collapse. These include midline glossectomy, mandibular advancement, limited mandibular osteotomies with genioglossal advancement, and hyoid bone suspension. These surgical approaches are available because 80% of patients with OSA have an obstruction at the retropalatal segment of the mouth, and 50% of these patients also have an obstruction at the retroglossal segment. 3
The technique of using a suspension screw to support the base of the tongue was first presented at the American Academy of Otolaryngology-Head and Neck Surgery annual meeting in 1998. 4
The technique of tongue advancement or tongue base stabilization involves the use of a soft tissue-to-bone anchor inserted intraorally in the mandible with an attached suture that is passed through the tongue. The suture loop causes traction on the tongue base (fig. 1
). By pulling the tongue forward and creating a small indentation at the base of the tongue, this technique might be used as part of a multimodal attempt at alleviating the symptoms of OSA in patients in whom a significant portion of disease was caused by tongue displacement. Initial results of the procedure have been positive. In a recent study, 5
16 patients underwent the procedure. Two patients had short-term complications related to pain and infection, and the procedure was reversed. These patients were excluded from the data analysis. Of the 14 other patients, varying rates of improvement in snoring were seen, and a statistically significant decrease of 53% in mean respiratory distress index was noted in all patients. However, this study had a short follow-up time of 6 months, and patients with severe obesity, as was the case with our patient, were excluded from the study. There were no cases of postoperative airway compromise.
Possible causes of airway obstruction in the current patient include soft tissue obstruction, laryngospasm, a foreign body, or an allergic reaction. Laryngospasm was not a possibility because before direct laryngoscopy and after cricothyrotomy neuromuscular blocking agents were administered to the patient, which should have relieved laryngospasm. Also, no foreign body was found. The swollen tissues might have been caused by an allergic reaction, but the patient had no other symptoms indicating an allergic reaction. The fact that the airway was manipulated during tongue suspension would indicate that this was the cause of the airway swelling in the current patient.
In conclusion, the anesthesiologist is faced with many procedures directed at relieving airway obstruction in patients with OSA. We report a case in which performance of a new procedure directed at alleviating the obstruction at the tongue base resulted in immediate postoperative life-threatening airway obstruction, necessitating emergency cricothyrotomy. Anesthesiologists must be prepared to deal with potential airway obstruction in patients with OSA and take measures to safeguard the airway. These methods might include delayed extu-bation, use of an endotracheal tube changer, or otolaryngologist standby for possible establishment of an emergency surgical airway.
1. DeRowe A, Woodson T: A minimally invasive technique for tongue base stabilization in obstructive sleep apnea. Otolaryngol Head Neck Surg 2000; 11: 41–6
2. Shepard JW, Olsen KD: Uvulopalatopharyngoplasty for the treatment of obstructive sleep apnea. Mayo Clin Proc 1990; 65: 1260–67
3. Kuna ST: Anatomy and physiology of upper airway obstruction, Principles and Practice of Sleep Medicine, 3rd edition. Edited by Kryger MH, et al. Philadelphia, Saunders, 2000, pp 840–58
4. Coleman J, Bick PA: Suspension sutures for the treatment of obstructive sleep apnea and snoring. Otolaryngol Clin North Am 1999; 32: 277–85
5. DeRowe A, Gunther E, Fibbi A, Lehtimaki K, Vahatalo K, Maurer J, Ophir D: Tongue-base suspension with a soft tissue-to-bone anchor for obstructive sleep apnea: Preliminary clinical results of a new minimally invasive technique. Otolaryngol Head Neck Surg 2000; 122: 100–3
© 2001 American Society of Anesthesiologists, Inc.