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Oropharyngeal Stenosis Leading to an Unanticipated Difficult Airway in a Patient After Uvulopalatopharyngoplasty: A Case Report and Review of the Literature

Boles, Kathryn S. DO, PharmD, MPH*; Casler, John D. MD; Porter, Steven B. MD*

doi: 10.1213/XAA.0000000000000758
Case Reports
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Oropharyngeal stenosis can manifest as a rare complication after surgery for obstructive sleep apnea or tonsillectomy. Scar tissue formation from oropharyngeal stenosis may impede tracheal intubation or laryngeal mask airway insertion. We report the case of an asymptomatic adult woman found to have oropharyngeal stenosis after induction of anesthesia and discuss the management of this challenging scenario. We also contrast oropharyngeal stenosis with nasopharyngeal stenosis, another rare complication of uvulopalatopharyngoplasty.

From the Departments of *Anesthesiology and Perioperative Medicine

Otolaryngology, Mayo Clinic, Jacksonville, Florida.

Accepted for publication January 29, 2018.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Address correspondence to Steven B. Porter, MD, Department of Anesthesiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224. Address e-mail to porter.steven@mayo.edu.

Oropharyngeal stenosis (OPS) may present as a delayed complication after upper airway surgery.1 Although more commonly reported in children after tonsillectomy or adenotonsillectomy, it may occur in adults who have undergone uvulopalatopharyngoplasty (UPPP) for treatment of obstructive sleep apnea (OSA).2,3

OPS occurs when scar tissue forms from the anterior tonsillar pillars and inferior tonsillar fossa to the base of the tongue.4 The adherent tissue creates a circumferential web blocking passage to the oropharynx. This differs from nasopharyngeal stenosis (NPS), another complication of UPPP, which can block passage through the nasopharynx.5,6

An unanticipated difficult airway during anesthetic induction may result if OPS is not identified preoperatively. We present a case of unsuccessful laryngeal mask airway (LMA) placement that led to the intraoperative diagnosis of OPS. The patient provided written consent for the publication of this report.

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CASE DESCRIPTION

A 54-year-old African American woman presented for outpatient hysteroscopy. Her medical history included breast cancer, type 2 diabetes mellitus, and obesity (body mass index of 33 kg/m2, neck circumference 40 cm). Her surgical history included bilateral mastectomies with breast implantation, UPPP with sinus surgery, and pilonidal cyst excision. Preoperatively, she was assessed as a Mallampati III classification as only the soft palate was identified. She related no known problems with anesthesia after her sinus and UPPP surgery.

The anesthetic plan included general anesthesia with a LMA. After induction with propofol, a size #4 LMA appeared to bounce back when trying to advance around the base of the tongue. A size #3 LMA was also unable to be passed. At this point, succinylcholine was administered and a video laryngoscope (Glidescope, Verathon, Bothell, WA) was used to attempt intubation. OPS with a circumferential web of tissue was identified on video laryngoscopy, preventing visualization of the vocal cords and glottic opening (Figure 1). An otolaryngologist was consulted in the operating room, who agreed with the working diagnosis from his visualization using the video laryngoscope. Although the patient could be mask ventilated with 2 providers, the presence of distal anatomic irregularities beyond the web’s opening could not be ruled out. Therefore, the anesthesia and surgical teams together decided to emerge from anesthesia given the elective nature of this surgery.

Figure 1.

Figure 1.

The patient followed up with the aforementioned otolaryngologist, who confirmed circumferential OPS with a 12-mm opening through which he placed a pediatric fiberoptic bronchoscope to visualize her vocal cords. The glottic opening and vocal cords appeared normal beyond the lesion, and her nares were without obstruction on fiberoptic examination (Supplemental Digital Content, Video 1, http://links.lww.com/AACR/A176).

The patient was brought back to the operating room for robotic transoral excision of the OPS. Transnasal intubation was planned due to the unobstructed pathway from the nasopharynx to the vocal cords. Her airway was topicalized with 4% lidocaine, and her nasal passage was premedicated with oxymetazoline 0.05% and 100 µg of phenylephrine. The patient then underwent awake nasal fiberoptic intubation with fentanyl sedation without difficulty (Figure 2).

Figure 2.

Figure 2.

The cicatricial web was opened bilaterally to the natural lateral pharyngeal wall recess using a cautery device. Inspired and expired oxygen concentrations were kept <30%. The patient emerged from anesthesia without incident and was kept overnight for observation after experiencing 1 episode of laryngospasm versus upper airway obstruction in the recovery room. No further complications occurred.

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DISCUSSION

Although previously attributed to infection, surgery now represents the most common cause of OPS.1,7 Historically considered a rare complication of upper airway surgery, more recent studies have shown an 8.2% prevalence of postoperative OPS in the pediatric population after lingual tonsillectomy and a 7.8% prevalence of OPS in the adult population after UPPP and transoral robotic surgery.1,2 Scar formation leading to OPS may cause symptomatic dyspnea on exertion, dysphagia, and sleep disordered breathing that can present 2–8 months after UPPP.1,8,9 However, OPS may also present with very mild symptoms that are dismissed or no symptoms at all.1 Risk factors for developing OPS include young age, keloid-forming tendency, excessive cautery, and deep dissection of tonsillar pillars.9 OPS developed in our patient after UPPP, although sarcoidosis, airway burn, and Behcet syndrome have been identified as rare, nonsurgical causes.8

NPS, a similar but distinct complication of UPPP surgery, occurs when fibrotic tissue forms from the soft palate to the posterior pharynx causing a narrowing of the nasopharynx.10 Essentially, NPS creates an axial web of tissue blocking the nasal passage, while OPS forms a coronal cicatrix that may obscure the oropharynx (Figure 3). In patients who previously underwent UPPP, oral breathing, hyponasal speech, and rhinorrhea may represent NPS, while dysphagia and continued OSA may identify either NPS or OPS.4 In patients with a history of UPPP, preoperative questioning should be directed to elicit symptoms of undiagnosed NPS or OPS.

Figure 3.

Figure 3.

Rarely, NPS and OPS can occur concomitantly, further impeding anesthetic management.4 Anesthesiologists should be aware of both complications of UPPP as each has its own anesthetic implications (Table). However, OPS represents the more challenging scenario due to the obstruction of the oropharynx making the passage of an endotracheal tube or LMA difficult, if not impossible.

Table.

Table.

Maintaining a high suspicion for OPS in patients who have previously undergone upper airway surgery or have any known risk factors for OPS may help identify patients at risk for a difficult intubation. Our patient related no significant signs or symptoms preoperatively that would alert the anesthesia team to the presence of severe OPS. Her history revealed no issues after her sinus/UPPP surgery, even undergoing general anesthesia in a subsequent surgery. However, when pressed after the discovery of this pharyngeal web, she did admit that food would “get stuck once in a while.” She was also noted to be a keloid former, which increases her chance of developing OPS.1,4 In patients with a surgical history of UPPP, it is imperative to inquire about keloid-forming tendency and active OPS symptoms, like dysphagia. Patients may dismiss these symptoms; however, they may provide an important preoperative clue to an impending difficult airway.

Physical examination represents equal importance for preoperative identification of OPS. Before surgery, our patient was labeled as a Mallampati III airway, because only the soft palate was visualized due to her tongue obscuring the inferior portion of the web. In the otolaryngology clinic after her canceled surgery, the superior portion of the cicatricial web could be visualized only with significant pressure on the tongue by using a tongue depressor (Figure 4). Therefore, if one suspects the presence of OPS, a complete oropharyngeal examination with the utilization of a light source and tongue depressor is paramount. Any abnormal finding should prompt further evaluation before elective surgery.

Figure 4.

Figure 4.

Although widely unrecognized in the anesthesia community, OPS should be considered as a cause of difficult airway. If one encounters OPS for the first time in the operating room during anesthetic induction, then the difficult airway algorithm should be followed. The inability to mask ventilate the patient during a difficult airway represents a true emergency. According to the American Society of Anesthesiologists Practice Guidelines for Management of Difficult Airway, the use of a supraglottic airway is recommended as the next step of management when mask ventilation is inadequate.11 It must be recognized, however, that the placement of an LMA in a patient with OPS may not be possible. Therefore, a surgical or percutaneous airway, nasal or retrograde intubation may be necessary in a patient with OPS.11

Fortunately, our patient was able to be mask ventilated by 2 providers. If urgent or emergent surgery must be continued, one can consider a mask ventilation technique or regional anesthesia with minimal sedation. If the airway must be secured in a patient with OPS, then nasal intubation with spontaneous respiration represents a viable option after ruling out NPS. These conditions may occur concomitantly, however, limiting safe options for airway management. Therefore, we recommend surgical exploration by an otolaryngologist before any elective surgery in a patient with OPS.

Although historically noted to be a pediatric complication after tonsillectomy or adenotonsillectomy, OPS now represents a significant complication in adults after UPPP to correct OSA.8 The anesthesiologist must be vigilant in both the preoperative history and physical examination because both can miss the opportunity to identify OPS. For patients with a surgical history that includes UPPP, the preoperative evaluation should include questions concerning keloid-forming tendency and current symptoms that may identify OPS. If preoperative questioning elicits concern for OPS, a directed airway examination with a tongue depressor and light source should occur before surgery. Any clinical suspicion for OPS should warrant consultation to an otolaryngologist to rule out concomitant NPS, because this would severely limit airway management options. Anesthetic techniques for patients with OPS include awake nasal intubation or regional anesthesia with minimal sedation. However, surgical correction of OPS should be considered before any elective surgery. With the increasing chance to encounter postsurgical OPS, anesthesia providers should focus on recognizing and anticipating this complication.

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DISCLOSURES

Name: Kathryn S. Boles, DO, PharmD, MPH.

Contribution: This author helped perform the literature review, acquire data, and write and revise the article.

Name: John D. Casler, MD.

Contribution: This author helped care for the patient and edit the article.

Name: Steven B. Porter, MD.

Contribution: This author helped care for the patient, conceive the report, and revise the article.

This manuscript was handled by: Raymond C. Roy, MD.

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REFERENCES

1. Prager JD, Hopkins BS, Propst EJ, Shott SR, Cotton RT. Oropharyngeal stenosis: a complication of multilevel, single-stage upper airway surgery in children. Arch Otolaryngol Head Neck Surg. 2010;136:11111115.
2. Cohen DS, Sekhsaria V, McCormick ME, Lin HS. Circumferential oropharyngeal stenosis after single stage transoral robotic surgery and standard uvulopalatopharyngoplasty for surgical treatment of obstructive sleep apnea: a report of five patients. 2014. Available at: http://www.triomeetingposters.org/wp-content/uploads/2014/05/C046.pdf. Accessed January 8, 2018.
3. Aneeza WH, Marina MB, Razif MY, Azimatun NA, Asma A, Sani A. Effects of uvulopalatopharyngoplasty: a seven year review. Med J Malaysia. 2011;66:129132.
4. McLaughlin KE, Jacobs IN, Todd NW, Gussack GS, Carlson G. Management of nasopharyngeal and oropharyngeal stenosis in children. Laryngoscope. 1997;107:13221331.
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7. Muderris T, Sevil E, Bercin S, Gul F, Kiris M. Oropharyngeal stenosis after transoral robotic lingual tonsillectomy. J Craniofac Surg. 2015;26:853855.
8. Nishimori M, Matsumoto M, Nakagawa H, Ichiishi N. Unanticipated difficult airway due to undiagnosed oropharyngeal stenosis: a case report. JA Clin Rep. 2016;2:10.
9. Eleff DJ, Tien DA, Anne S. Oropharyngeal stenosis: a rare complication following adenotonsillectomy. Am J Otolaryngol. 2016;37:207209.
10. Korkmaz H, Selcuk OT, Tatar EC, Saylam G, Ozdek A. Complete nasopharyngeal stenosis: presentation of a rare case. Eurasian J Med. 2012;44:185187.
11. Apfelbaum JL, Hagberg CA, Caplan RA, et al.; American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118:251270.

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