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Role of Ultrasound in Emergency Front of Neck Access: A Case Report and Review of Literature

Ansari, Umair FCAI; Malhas, Laith FRCA; Mendonca, Cyprian FRCA

doi: 10.1213/XAA.0000000000001089
Case Reports

Emergency front of neck access (eFONA) is a lifesaving procedure in a cannot intubate cannot oxygenate (CICO) situation. We report a case of a patient who presented to the emergency department (ED) in extremis with a difficult airway. A history of multiple neck surgeries and permanent tracheostomy from birth until the age of 17 years complicated his airway management. Altered neck anatomy led to failed intubation and oxygenation. EFONA was established with the use of rapid ultrasound imaging and using the scalpel-bougie-tube technique. We present a review of literature relating to the use of ultrasound during emergency airway management.

From the University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom.

Accepted for publication August 7, 2019.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Umair Ansari, FCAI, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom. Address e-mail to

Emergency front of neck access (eFONA) is the final step for managing an unanticipated difficult intubation. The Difficult Airway Society (DAS) guidelines describe a scalpel-bougie-tube technique for eFONA.1 In an impalpable cricothyroid membrane, due to difficult neck anatomy, eFONA can be extremely difficult, necessitating a vertical skin incision over the anterior aspect of the neck and blunt finger dissection to locate the cricothyroid membrane. Electively, the cricothyroid membrane can be palpated and identified during preoperative assessment, and if impalpable, ultrasound can be used to locate the cricothyroid membrane.2,3 In an emergency, ultrasound may not be immediately available and locating an ultrasound may delay emergency airway access. If immediately available, its use has improved success rate and reduced procedure time.4 This clinical case illustrates the challenges an emergency physician may face in a cannot intubate cannot oxygenate (CICO) situation due to difficult neck anatomy.

Written patient consent was obtained before his discharge home.

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A 37-year-old male patient with a body mass index (BMI) of 17.2 kg/m2 presented to the emergency department (ED) with flu-like symptoms and shortness of breath. His history included cystic hygroma on his right side of neck, which had required multiple operations, and a permanent tracheostomy from birth until 17 years old. He was a smoker but took no regular medication and had no known allergies.

An assessment by an emergency medicine physician found him to be sweating with excessive respiratory effort. Examination revealed decreased air entry on the left and minimal air entry on the right (possibly consequent to previous right-sided video-assisted thoracic surgery). His observations were as follows: heart rate (HR) = 102 bpm, blood pressure (BP) = 137/76 mm Hg, temperature = 37.3°C, respiratory rate (RR) = 26, and oxygen saturations (Sao2) = 89% on 10 L/min oxygen. He was alert and communicative.

Due to his deteriorating clinical condition, he was transferred to the resuscitation area at 07:00 hours, and the intensive care physicians and senior resident anesthetist were summoned. He rapidly deteriorated with progressive decreased conscious level and unrecordable oxygen saturations.

No oxygenation was achieved with attempted facemask ventilation. At 07:05, a respiratory arrest was declared; an intubating dose of rocuronium was administered intravenously; and tracheal intubation was attempted at 07:06 hours. Initial direct laryngoscopy and bougie placement failed due to altered anatomy and no discernible landmarks. The oropharynx contained solid abnormal tissue displacing the airway to the left; an epiglottis-looking structure rotated to the left could be seen at a perpendicular angle, but a bougie could not pass behind it. A further attempt was made with a video laryngoscope (Pentax AWS; Hoya Service Corporation, Tokyo, Japan), but this also failed to visualize the glottic inlet. Immediately a “CICO” situation was declared. During the intubation attempts, an arterial line was inserted into the left radial artery and the arterial blood pressure was monitored.

Due to the previous cystic hygroma with multiple previous surgeries, there was difficulty identifying anatomical structures of the neck. Most tissue was firm, scarred, and hard to feel or abnormal. The main cartilaginous-feeling structure was situated left of the midline, but no contours within it were identifiable. The previous tracheostomy site was evident, but the clinical history was unclear to determine whether there was any subglottic stenosis resulting from it. Given the anticipated difficulty in performing eFONA in abnormal tissue with midline shift, an ultrasound machine (Venue 50; GE Medical Systems Ltd, Buckinghamshire, United Kingdom), which was immediately available, was switched on.

An ultrasound scan was performed in the transverse plane in the cephalocaudal direction. Little recognizable anatomy was seen until about 2 cm above the suprasternal notch, where the trachea was identified close to the midline, with no major overlying vessels or thyroid tissue.

At 07:12 hours, there was loss of cardiac output, absence of central pulse was confirmed, and a pulseless electrical activity (PEA) cardiac arrest was declared, with commencement of chest compressions and 1-mg intravenous epinephrine administered.

A vertical 4-cm-long skin incision was performed using a size 10 scalpel over the area identified with ultrasound. Blunt finger dissection identified the trachea with its cartilaginous rings. A horizontal stab incision was made in the trachea, and a bougie was passed without resistance. A 6-mm internal diameter cuffed tracheal tube was railroaded over the bougie. The bougie was removed; the tracheal tube cuff was inflated; and ventilation was confirmed by capnography at 07:13 hours.

A rhythm check showed continued PEA, and a second cycle of cardiopulmonary resuscitation (CPR)—as per advanced life support guidelines—was started. At the end of the second cycle (07:16 hours), return of spontaneous circulation was identified on the arterial line monitor with an increase in end-tidal CO2. Sedation was started using propofol infusion.

On auscultation, there were breath sounds over the left lung but none over the right. Given the history of previous thoracic surgery, this was possibly a normal finding for the patient. The linear ultrasound probe was positioned on the anterior chest wall, identifying no movement of the right lung with ventilation. The cuff was deflated and the tracheal tube withdrawn until right lung movement was evident on ultrasound, the cuff reinflated and the tube secured. A computerized tomography (CT) scan of the neck took place immediately after the event. This demonstrated significant deviation and distortion of the larynx and trachea (Figure 1).

Figure 1.

Figure 1.

The patient was transferred to a critical care area and kept sedated, and ventilator support continued. Later that day, the patient was transferred to theater for conversion to a formal tracheostomy (Figure 2).

Figure 2.

Figure 2.

A sedation hold was performed 2 hours after the tracheostomy, and the patient awoke appropriately with no neurological deficit or memory of events after arrival to the ED. He was stepped down from critical care within 24 hours, and on day 4, he was discharged home without complications.

Written consent was obtained from the patient for publication of this case report.

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Cystic hygroma is not a rare condition, with an incidence of about 1 in 8000 births (75% affecting the neck). In this case, scarring and disruption of the normal course of the trachea and adjacent structures resulted from multiple surgeries (Figure 3), necessitating a tracheostomy. A literature search revealed numerous articles citing anesthetic difficulties with adult onset of cystic hygroma but none due to the sequelae of surgery after a pediatric presentation of cystic hygroma.5,6

Figure 3.

Figure 3.

The DAS 2015 guidelines recommend use of an ultrasound in emergency surgical cricothyroidotomy if it is readily available and does not delay the cricothyroidotomy.1

The use of ultrasound for identification of the midline of the trachea and locating the cricothyroid membrane is well documented.7 Ultrasound has been used in real time to guide surgical cricothyroidotomy in cadavers (simulation).8 The use of ultrasound to locate the trachea in an anticipated difficult airway has been reported, and this significantly decreases injuries to the larynx and increases probability of success.9,10

Ultrasound in real time has been used electively within intensive care for the identification of trachea and percutaneous needle access to the trachea including needle positioning.11–14 However, due to the rare and emergency nature, there is paucity of literature on using ultrasound for emergency airway rescue in a CICO event.

We feel that some measures could have improved the management for our patient. High-flow nasal oxygen administration on admission to the ED and continuation during apnea may have increased time for airway management.15 The DAS 2015 guidelines recommend insertion of a supraglottic airway device (SAD) after a failed attempt at tracheal intubation.1 Successful oxygenation through a SAD provides an option to intubate the trachea using a flexible fiberscope. In our patient, due to rapid clinical deterioration, the operator decided to proceed to a surgical airway rather than attempting a SAD. To facilitate a surgical airway, an intubation dose of rocuronium was administered after respiratory arrest. The 2015 DAS guidelines recommend complete neuromuscular blockade before an attempt at eFONA.1 Successful management of CICO depends on anticipation and preparation for airway management. In this case, an ultrasound scan of the neck on admission to the ED could have been beneficial in planning a percutaneous emergency airway.2

EFONA is a stressful situation which is rarely encountered during an anesthetist’s career. The use of an ultrasound to identify and mark the trachea not only provides a marker for incision but helps overcome the psychological barrier of progressing to a surgical airway during a failed intubation.

This case highlights the utility of ultrasound guidance as an aid to identification of the midline of the trachea. Once the midline was evident, the impalpable technique for cricothyroidotomy was effective in securing the airway. We would recommend that ultrasound is used routinely to identify airway anatomy to increase skill levels among anesthetists and emergency care physicians in airway ultrasound. Therefore, in an emergency, immediate availability of ultrasound improves the success rate of front of neck access.

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Name: Umair Ansari, FCAI.

Contribution: This author helped conduct the literature search, draft the manuscript, and contribute to the final revision.

Name: Laith Malhas, FRCA.

Contribution: This author helped manage the patient, draft the case report, contribute the figures, and contribute to the final revision.

Name: Cyprian Mendonca, FRCA.

Contribution: This author helped provide clinical expertise in ultrasound and front of neck access, revise the manuscript before submission, and contribute to the final revision.

This manuscript was handled by: Kent H. Rehfeldt, MD.


BMI = = body mass index

BP = = blood pressure

CC = = cricoid cartilage

CICO = = cannot intubate cannot ventilate

CH = = cystic hygroma

CPR = = cardiopulmonary resuscitation

CT = = computerized tomography

DAS = = Difficult Airway Society

ED = = emergency department

eFONA = = emergency front of neck access

ETT = = endotracheal tube

HB = = hyoid bone

HR = = heart rate

MRI = = magnetic resonance imaging

PEA = = pulseless electrical activity

RR = = respiratory rate

SAD = = supraglottic airway device

Sao2 = = oxygen saturations

SS = = evidence of subglottic stenosis

TC = = thyroid cartilage

Thy = = thyroid gland

VC = = level of vocal cords

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