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Mucosal Erosion of the Cricoid Cartilage After the Use of an i-Gel Supraglottic Airway Device in a Patient with Diffuse Idiopathic Skeletal Hyperostosis

Schaer, Andreas C. MD; Keel, Marius J. B. MD; Dubach, Patrick MD; Greif, Robert MD; Luyet, Cédric MD; Theiler, Lorenz MD

doi: 10.1213/XAA.0000000000000049
Case Reports: Case Report

After standard hip arthroplasty, an 82-year-old patient with previously undiagnosed diffuse idiopathic skeletal hyperostosis of the cervical spine experienced life-threatening side effects after use of a supraglottic airway device (i-gel). Extensive mucosal erosion and denudation of the cricoid cartilage caused postoperative supraglottic swelling and prolonged respiratory failure requiring tracheostomy. In this case report, we highlight the importance of evaluating risk factors for failure of supraglottic airway devices.

From the Departments of *Anesthesiology and Pain Therapy, Orthopedic and Trauma Surgery, and Otorhinolaryngology, Head and Neck Surgery, Bern University Hospital and University of Bern, Bern, Switzerland.

Accepted for publication October 28, 2013.

Funding: No external funding.

The authors declare no conflicts of interest.

Address correspondence to Lorenz Theiler, MD, University Department of Anesthesiology and Pain Therapy, Bern University Hospital and University of Bern, Inselspital, CH-3010 Bern, Switzerland. Address e-mail to

The i-gel laryngeal mask is a supraglottic airway device (SGA) without an inflatable cuff. Instead, a soft elastomer seals the device to the glottic structures. As with any other second-generation SGA, side effects, such as mild sore throat, are common.1 However, these effects are usually more benign compared with side effects caused by tracheal tubes.2

The patient gave written consent for publication of this report, including all pictures.

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An 82-year-old man with previously undiagnosed diffuse idiopathic skeletal hyperostosis (DISH) underwent a standard hip arthroplasty under general anesthesia. The airway was secured using an i-gel SGA.

His medical history included right upper lung emphysema, coronary heart disease with percutaneous transluminal coronary angioplasty stenting in 2004, and well-controlled type II diabetes mellitus. Preoperative airway assessment included Mallampati score (class III), mouth opening (>4 cm), and measurement of the thyromental distance (>6 cm). Although the range of motion of his head and neck was “moderately impaired” (oropharyngeal angle >90°), no suspicion of difficult SGA management was raised. After IV induction with propofol and fentanyl, a size #5 i-gel was easily inserted and total IV anesthesia was maintained with propofol throughout the 95-minute surgical procedure. No perioperative complications including regurgitation were reported. An orogastric tube was not inserted, and there was no blood on the device on its removal. Three days after surgery, dysphagia, cough, and clear discharge developed. An examination by an otolaryngologist revealed supraglottic edema. A laryngotracheitis was assumed, and a therapy with broad-spectrum antibiotic and steroids was initiated. The patient was discharged home 2 weeks after surgery.

Emergency readmission occurred 1 day after discharge due to severe dyspnea and difficulty in swallowing. Because of presumed partial airway obstruction, awake nasotracheal intubation was performed. A computed tomography scan demonstrated supraglottic edema and a thickening of the tracheal wall with a dilated tracheal lumen (Fig. 1). No mediastinal pathology was found, but instead marked degenerative changes of the cervical spine, consistent with DISH, and voluminous spondylophytes of the ventral cervical spine levels C2-7 were observed (Fig. 1). Because of the tracheal dilation, sealing of the tracheal tube cuff became increasingly difficult and a tracheostomy was performed the following day without complications. Treatment with antibiotics and steroids resulted in no improvement, and due to the continued respiratory problems with supraglottic stenosis, the patient was transferred to a tertiary care hospital for further treatment.

Figure 1

Figure 1

Resection of the spondylophytes and osteosynthetic stabilization of the cervical spine C5-7 were performed through a left transcervical access (Fig. 2) 2 days after admission. A panendoscopy demonstrated extensive mucosal hypopharyngeal and upper esophageal erosions at the level of C5 with fibrous coatings but without perforation and mucosal necrosis with denudation of the cricoid cartilage 1 × 2 cm in diameter (Fig. 3). A Gastrografin swallow test excluded mediastinal leakage, and therefore antibiotic therapy was suspended. Despite intensive physiotherapy, recurrent aspiration made a percutaneous endoscopic gastrostomy necessary for 1 week to ensure that the patient received proper nourishment. Six days after the orthopedic surgical intervention and after a further (and uneventful) postoperative course, the patient was discharged home.

Figure 2

Figure 2

Figure 3

Figure 3

Because of his full recovery, the patient refused a control panendoscopy 6 weeks later.

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We report an extreme case of hypopharyngeal injury. To our knowledge, no studies have evaluated patient-related risk factors for hypopharyngeal injury associated with the use of SGAs. However, we suggest the duration of anesthesia and anatomical variations as contributing factors to hypopharyngeal injury. Cuff pressure has been shown to directly correlate with mucosal pressure being greatest in the hypopharynx,3,4 especially opposite the cervical vertebrae.5 Mucosal pressure from the i-gel has been demonstrated to be generally low (5–9.3 cm H2O).4 Historically, the recommended size of SGAs is based on weight. In this case, despite the patient’s moderate weight of 71 kg (size 171 cm), a size #5 i-gel was used, which was larger than recommended. Recent evidence suggests that the correct size of an SGA depends not only on weight, but also on height, age, and gender.1 However, in the case of the i-gel, perhaps a more prudent approach to achieving a proper size would be to choose the smallest size providing an effective seal.

DISH is a degenerative disease of unknown origin, more common in men than women. Even though often asymptomatic and therefore not detected, dysphagia, airway obstruction, and dysphonia can be found in patients having DISH. However, symptoms are rarely severe or even life threatening.6,7 Studies suggest that the prevalence of DISH ranges from 10% to 35% among patients aged >50 years.8 The prevalence of airway complications from DISH, however, is unknown. Anterior displacement of the larynx with subglottic stenosis and bulging of the pharyngeal wall is reported to cause difficult tracheal intubation associated with DISH.9–12 In these case reports, the distortion of the pharyngeal anatomy creating the difficulties in airway management during the anesthesia intervention was caused by ventral cervical osteophytes compressing the pharyngeal wall and secondary tissue inflammation.

Among the many predictors for difficult intubation, little attention is directed toward the anatomy of the patient’s cervical spine.13 If tracheal intubation fails, difficult airway management guidelines include the use of SGAs.14,15 Unfortunately, recently published risk factors for difficult SGA ventilation overlap with risk factors for difficult mask ventilation and difficult laryngoscopy, such as impaired mandibular subluxation and old age.1,16 Published evidence does demonstrate limited mouth opening, oropharyngeal pathology, and restricted atlanto-occipital joint extension (oropharyngeal angle <90°) to be important factors that make laryngeal mask airway (and most likely other SGAs as well) placement difficult.17 Additionally, a reduced range of motion may suggest otherwise undiagnosed pathologies such as DISH. Considering the frequent prevalence for DISH and other rheumatologic diseases in older patients, high suspicion for potential adverse events caused by spondylophytes that may not be diagnosed through standard diagnostic tests may be warranted. If cervical spine imaging is available, reviewing those images should be considered as part of the airway work-up. Our case demonstrates that cervical anatomy influences the performance of SGAs not only because of reduced range of motion of the neck that may lead to difficult placement, but also because of spondylophytes leading to serious adverse outcomes.

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