Retropharyngeal abscesses (RPAs) are deep neck space infections that can lead to life-threatening airway emergencies and other catastrophic complications. RPAs demand prompt diagnosis and early management. A definitive airway must be established when there is airway compromise. This can be difficult in an uncooperative patient.
We present the case of a 12-year-old girl with mediastinitis and both tracheal compression and extreme anterior displacement from a large retropharyngeal and posterior mediastinal abscess secondary to traumatic esophageal perforation, who received successful awake nasal fiberoptic intubation (FOI). This case report has been reviewed by the patient’s family, and written permission was obtained for the authors to publish the report.
A 12-year-old girl (42.4 kg, 4′11″, normal development) with a medical history of recurrent croup, presented to the emergency room in acute respiratory distress. She stated that 1 week ago, she had eaten a tuna sandwich with mayonnaise from a broken glass jar. She began choking, and her father performed the Heimlich maneuver, which forced her to cough out parts of the sandwich. Over the next few days, she had worsening throat pain, difficulty swallowing solids, and substernal chest pain. Overnight she had progressive shortness of breath. The next morning she had awakened with difficulty breathing not relieved with albuterol treatments, which finally prompted her parents to take her to the emergency room.
In the emergency room, she complained of neck pain, stiffness, and increasing difficulty swallowing. On examination, she was febrile to 39°C, sitting upright, and exhibited nasal flaring and copious oral secretions. She also displayed suprasternal and intercostal retractions, diffuse bilateral wheezing, decreased neck range of motion, and anterior cervical lymphadenopathy, and tenderness.
Radiographs of the neck and chest revealed a large retropharyngeal collection with mediastinal extension, and anterior and leftward deviation of the trachea (Fig. 1). Computed tomography of the neck and chest showed a foreign body in the posterior mediastinum that suggested esophageal perforation. Also noted was a large fluid collection with an air-fluid level measuring 16.3 cm that extended from the retropharyngeal space to the posterior mediastinum that was displacing the trachea anteriorly (Fig. 2). There was marked tracheal compression at the level of the brachiocephalic artery, measuring 0.6 × 0.4 cm at its narrowest (Fig. 3).
The patient was taken emergently to the operating room with plans for an awake oral FOI and drainage of the abscess through the chest via a thoracoscopic approach. An otolaryngologist was present for the possibility of an emergent tracheostomy. A second anesthesiologist and a child life specialist were in the room as well.
The patient was administered oxygen in the sitting position with the child life specialist next to her. She was given 0.2 mg of glycopyrrolate IV to reduce oral secretions, and her heart rate increased from 110 to 130 seconds. The patient was able to tolerate the 4% lidocaine nebulizer treatment for a few minutes only, and as a result, oral intubation was aborted.
With the otolaryngologist present, the decision was then made to administer 2 mg of midazolam (0.05 mg/kg) for light sedation, because the patient was already somnolent and showed signs of fatigue. Bilateral nares were sprayed with 0.05% oxymetazoline. No local anesthetics or nerve blocks were used. With the assistance of a second anesthesiologist stabilizing the patient’s head, a flexible fiberoptic bronchoscope (3.0 Karl Storz; Karl Storz Endoscopy-America, Inc., El Segundo, CA) was passed through the left naris, advanced posteriorly, and passed through the vocal cords to identify the carina. Oral secretions were still abundant and required frequent suctioning. The abscess was not evident during passage of the bronchoscope. Coughing or retching did not occur, and no local anesthetic was applied to the vocal cords through the scope.
Intubation was accomplished using a 5.5-mm endotracheal tube, which had been selected by the otolaryngologist on review of imaging. A bronchial blocker (5.0 Fr Arndt; Cook Medical, Bloomington, IN) was then inserted into the right mainstem bronchus to isolate the left lung for ventilation and to assist the surgeon with visualization of the abscess via the posterior mediastinum.
Anesthesia was then induced with 80 mg propofol and maintained with sevoflurane, 100% oxygen, and rocuronium. The patient underwent successful right video-assisted thoracoscopic drainage of the posterior mediastinal abscess and removal of a 2.5-cm glass shard from the retroesophageal space (Fig. 4). The patient was transferred to the pediatric intensive care unit while intubated and was subsequently extubated on postoperative day 2. She had no recollection of events in the operating room after having received midazolam, including the intubation.
Pediatric RPA is uncommon and mostly occurs in boys between the ages of 3 and 5 years.1 The majority of cases are suppurative changes within a lymph node.2 Management includes IV antibiotics with or without surgical drainage, typically by a transoral approach. In our patient, the etiology was traumatic esophageal perforation from ingestion of a glass shard. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of >24 hours after perforation can result in up to 40% mortality.3 Deep neck space infections secondary to trauma are typically seen in older children and adults. Complications such as airway obstruction and spread to nearby anatomic structures create the potential for significant morbidity and mortality.
Mediastinitis is a feared complication of RPA that occurs when infection spreads along the neck’s deep fascial planes into the mediastinum. The mortality rate of pediatric mediastinitis secondary to traumatic esophageal perforation is unknown. Adult studies cite a 30% to 40% or higher mortality rate for all infectious causes of mediastinitis.4 Early recognition, emergent airway management, and aggressive surgical drainage and antibiotics were paramount in the survival of our patient.
A number of factors in patients with deep neck infections are problematic for intubation through rigid laryngoscopy, including airway edema, impaired neck range of motion, mass effect distorting normal anatomy, and the risk of airway collapse on administration of a muscle relaxant.5–8 For these reasons, the use of inhaled anesthetics in children who were spontaneously ventilating was believed to be ideal; however, the use of gases has been reported in this population to be associated with laryngospasm, airway edema, and difficult reintubation.9–11 Therefore, awake FOI is recommended for adults and older children who are able to tolerate the procedure.12,13
Children can be prepared by child life specialists for awake intubation even in emergent situations. Adequate topicalization in these cooperative awake patients can prevent laryngospasm and acute airway loss, which would necessitate emergent tracheostomy. However, an uncooperative child can limit topicalization of the oropharynx and prohibit oropharyngeal FOI. When this occurred in our case, the planned awake oral FOI was converted to an awake nasal FOI, with the patient supported in the sitting, upright position after light sedation. Our patient did not receive any nerve blocks and could only tolerate the lidocaine nebulizer treatment for a few minutes; however, this was sufficient to allow her to tolerate the bronchoscope without coughing or retching. If this approach had failed, or if sudden rupture of the abscess had occurred, an emergent tracheostomy would have been performed.14
With the marked tracheal compression and copious oral secretions in our patient, increasing the amount of sedation or using an inhaled induction technique would likely have caused the patient to lose pharyngeal reflexes and airway patency.15 Sedation reduces anxiety, improves intubation conditions, and minimizes repeat airway instrumentation that results in mucosal bleeding. In this case, mild sedation was warranted because of the major anxiety and poor cooperation of our patient.
Many agents have been used alone or in combination for sedation in awake FOI, including midazolam, fentanyl, propofol, dexmedetomidine, remifentanil, and ketamine. One commonly used combination consisting of midazolam and fentanyl has been shown to increase the frequency of hypoxemia and apnea, necessitating careful titration.16 A possible alternative is dexmedetomidine with midazolam; patients treated with this combination were significantly calmer and more cooperative during awake FOI and had fewer adverse reactions than those treated with only midazolam.17
Antisialagogues can be used to reduce oral secretions in cases of RPA. Administration of 0.2 mg glycopyrrolate IV along with fastidious suctioning was enough to provide an adequate view of the structures for intubation. For this anxious patient, administration of additional glycopyrrolate was deemed unnecessary, given that it would exacerbate the tachycardia, and an adequate view had already been obtained.
Pediatric RPAs can be life-threatening when there is airway compromise. Adequate preparation by child life specialists can allow for awake FOI to proceed easily in a well-informed, cooperative child who understands the procedure. However, anesthesiologists must also be prepared for airway emergencies in uncooperative patients, especially in children. In these patients, limited sedation may play an important role in facilitating intubation, despite the known risk of jeopardizing airway patency. An awake oral FOI should be attempted first. If this fails, the next approach would be an awake nasal FOI. If neither oral nor nasal FOI attempts are successful, then a tracheostomy will be necessary. Increasing the level of sedation should be performed only when the equipment and experienced personnel for an emergent surgical airway are present. A second anesthesiologist or qualified anesthesia provider should also be present for assistance.
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