key: cord-0747862-hzycbnov
authors: Tsunoda, Atsunobu; Kobayashi, Yuko; Tou, Miri; Sonoda, Kenji; Arai, Shinpei; Anzai, Takashi; Matsumoto, Fumihiko
title: Emergency videoendoscopic endonasal tracheal intubation for severe upper airway stenosis()()
date: 2020-10-22
journal: Am J Otolaryngol
DOI: 10.1016/j.amjoto.2020.102779
sha: fe7e6775c8a31b93e800e28f93ceb8c5f9daef7b
doc_id: 747862
cord_uid: hzycbnov

PURPOSE: Upper airway stenosis is one of the most formidable situations in medicine and is frequently encountered in the ENT clinic. We introduce here our method of emergency endonasal endotracheal intubation under videoendoscopic observation. METHODS: Transnasal endoscopic observation was done, and the region of airway stenosis was detected. Then, the endotracheal tube was prepared and the endoscope was inserted into the tube. The endoscope with tube was inserted up to the larynx. Immediately after the administration of lidocaine to the larynx, the endoscope with tube was inserted to the endolarynx and then to the trachea. The endotracheal tube was tightly held in the nostril, and the endoscope was removed. RESULTS: We have encountered four cases this year. The primary disease developing airway stenosis was acute epiglottitis due to pharyngeal and deep neck abscesses in three cases and laryngeal edema due to Ludwig's angina. All patients underwent uneventful intubation, and dyspnea was immediately ceased. CONCLUSION: In cases showing severe suffocation, the clinician should perform airway maintenance even in an outpatient setting apart from a more monitored setting like the operation room. This technique resembles the usual nasal endoscopic laryngeal observation and is done even in the usual ENT office and/or emergency room. The supine position tends to worsen airway stenosis in patients with upper airway stenosis; however, this technique can be performed in a sitting or semi-sitting position. This method is less invasive for patients and also reduces the risk to the medical staff, especially in this COVID-19 era.

Upper airway stenosis develops suffocation and is one of the most formidable situations in medicine. Especially for ENT clinicians, upper airway stenosis is frequently encountered due to infection in the otolaryngological field. In such cases, emergent airway maintenance is required, otherwise the patient will die or have severe sequelae even in the ENT outpatient clinic. The most common region causing upper airway stenosis is the larynx. In these situations, endotracheal intubation, cricothyrotomy, or tracheostomy is performed to prevent suffocation [1] . However, these techniques have potential risks of nosocomial infection from the patient's coughing, sputum, and blood. In addition, these techniques are usually done in a supine position; however, this for patients. This technique allows patients to keep their sitting position, and this position is also familiar to ENT doctors. Using an endoscope, transnasal intubation becomes much easier and safer.

The method is performed in the same fashion as the usual use of a flexible endoscope, so it is familiar to ENT doctors. The size of the tracheal tube is an important factor. An 8 mm tube is too bold to use for endonasal intubation for most patients. We recommend a 7.0 mm endotracheal tube, but a 6.0 mm tube is also usable. Our method is much easier for clinicians and less invasive for patients. However, this technique should be performed in limited situations as follows:

1. In very urgent situations to prevent suffocation; 2. At the least, the vocal cords are visible; and 3. Alternate methods for airway maintenance, such as cricothyroidotomy, are ready.

Although this method is applied in extreme situations, we are convinced that our method reduces the risk to both the patient and the medical staff, especially during this COVID-19 era. 

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