Tracheal intubation may be difficult in patients with cervical osteophytes [1-3]. We suggest that, in these patients, the laryngeal function may be impaired and cricoid pressure may be ineffective.
A 79-year-old man with Forestier's disease was scheduled for surgical removal of cervical osteophytes. He complained of difficulty in swallowing and frequent choking during drinking. A lateral X-ray showed large osteophytes extending anteriorly from the 2nd to the upper edge of the 5th cervical vertebrae (Fig. 1). Computed tomography revealed that the larynx, including the upper edge of the cricoid cartilage, was displaced anteriorly by the osteophytes and both the hypopharynx and the upper segment of the oesophagus were splinted open (Fig. 2).
Cinegraphy (video swallow) showed that on swallowing there was marked pooling of the liquid in the valleculae and pyriform fossae, and a considerable amount of liquid entered the larynx (Fig. 3). The 'Mallampati score' was class 1 with wide mouth opening. It was possible to move the larynx to the lateral side, but not towards the cervical vertebrae.
As reported previously [1-3], there was some difficulty in tracheal intubation. It was noted that the oesophagus was splinted open. The risk of pulmonary aspiration would be likely to be high in this patient had he had a full stomach, because cricoid pressure is unlikely to compress the hypopharynx effectively, and because regurgitated material may pool in the hypopharynx and be aspirated.
We suggest that large cervical osteophytes may impair the pharyngo-laryngeal reflexes and might splint the oesophagus open, rendering cricoid pressure ineffective. Awake tracheal intubation should be considered in these patients.
Department of Anaesthetics and Intensive Care Medicine, University of Wales College of Medicine, Heath Park, Cardiff, UK
1 Lee HC, Andree RA. Cervical spondylosis and difficult intubation. Anesth Analg
2 Ranasinghe DN, Calder I. Large cervical osteophyte - another cause of difficult flexible fibreoptic intubation. Anaesthesia
3 Broadway JW. Forestier's disease (ankylosing hyperostosis): a cause for difficult tracheal intubation. Anaesthesia