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Endotracheal intubation with flexible fiberoptic bronchoscopy in patients with abnormal anatomic conditions of the head and neck.


We performed a retrospective chart review to evaluate the indications for endotracheal intubation via flexible fiberoptic bronchoscopy in patients who were scheduled for surgery or who were hospitalized in the intensive care unit of our 1,100-bed, tertiary care university hospital. We reviewed 9,201 clinical records of anesthetic procedures during which endotracheal intubation had been performed from January to December 2002. We identified 66 patients who had been intubated with flexible fiberoptic bronchoscopy. On preanesthetic examination, 61 of these patients had been found to be poor candidates for conventional laryngoscopic intubation--51 because of abnormal head and neck anatomy and 10 because of reduced visual access to the airway (Mallampati class IV). The remaining 5 patients were intubated via flexible fiberoptic bronchoscopy after con ventional intubation had failed during emergency surgery. Our study emphasizes (1) the importance of the preanesthetic examination of surgical patients, to identify those in whom conventional intubation would likely be problematic, and (2) the need to have fiberoptic bronchoscopes and an anesthesiologist or bronchoscopist skilled in their use available in operating suites and intensive care units.


Endotracheal intubation for general anesthesia is usually performed with conventional (direct) laryngoscopy, (1-4) but at times introducing an endotracheal tube is difficult. (5) In these cases, the patient cannot be well oxygenated, and severe hypoxemia and even hypercapnia can occur, with a high risk of death. (6,7) Rogers and Benumof have identified a number of airway problems that make tracheal intubation very difficult and/or dangerous. (8)

Endotracheal intubation via flexible fiberoptic bronchoscopy (FFB) can be performed when intubation via direct laryngoscopy is impossible or when it is expected to be problematic. Failed intubation via direct laryngoscopy may, in fact, necessitate emergency FFB intubation.

Difficult intubation by direct laryngoscopy can be predicted in patients with abnormal anatomic features. (9,10) Therefore, the upper airways should always be examined preoperatively to detect such abnormalities as temporomandibular ankylosis, cervical spine abnormalities, and congenital malformations of the mandible and larynx. (11) FFB-guided intubation can be performed with topical or general anesthesia.

A system for evaluating the oropharynx, devised by Mallampati et al in 1985, identifies four classes of patients. (12) In Mallampati class I, the soft palate, faucial pillars, and uvula are easily seen; in class II, the same structures are seen, but the uvula is masked by the base of the tongue; in class III, only the soft palate can be visualized; and in class IV, only the hard palate that is in contact with the tongue can be seen. (12) Patients in classes III and IV are candidates for FFB intubation.

Other authors have also addressed the problem of difficult intubation. (13-16) The multivariate airway risk index with logistic regression, for example, proposed by el-Ganzouri et al, (16) accurately predicts possible intubation failures. Their approach takes into account conditions related to the airway, such as the mouth opening, thyromental distance, oropharyngeal (Mallampati) classification, neck mobility, ability to advance the lower jaw, body weight, and a history of difficult tracheal intubation. (16) The authors detected poor conditions for tracheal intubation in 107 (1%) and poor mask ventilation in 8 (0.07%) of 10,507 cases studied.

Researchers have found that it is easier to place an endotracheal tube with a video-assisted fiberoptic technique. (17-19) Endotracheal intubation may also be difficult in patients in intensive care, and FFB-guided intubation is sometimes indicated in these patients. (20,21)

Patients and methods

Our objective was to evaluate the indications for tracheal FFB-guided intubation (performed by the Departments of Anesthesiology and Pneumology) in patients who were scheduled for surgery or who were hospitalized in the intensive care unit of a 1,100-bed, tertiary care university hospital. Of 9,201 patients undergoing general anesthesia from January to December 2002, the charts of all patients subjected to FFB endotracheal intubation were studied. Age, gender, diagnosis, type of anesthesia, French (Fr) endotracheal tube size (range: 5.5 to 7.0 Fr), and secondary complications of the procedure were recorded.

Intubations were performed with a Pentax FFB and monitored with Sony Corporation's Image Management System, as described by Prakash, (11) by an anesthesia team trained in the use of FFB intubation. The endotracheal tube was placed over the FFB and introduced directly through the glottis into the trachea. Proper oxygenation was administered to the patient by means of an adaptor.

From the 9,201 anesthetic procedures reviewed, we selected 66 (0.72%) surgical patients for our study in whom intubation with FFB had been performed: 27 (41%) were males and 39 (59%) were females. Average age was 32.9 years (range: 16 to 72 years).

FFB intubations were carried out under general anesthesia in 46 cases (69.7%) and with lidocaine topical anesthesia in 20 (30.3%) awake patients (p [less than or equal to] 0.05, CI 95%). The bronchoscope was introduced perorally in 40 patients (60.6%) and transnasally in 26 (39.4%) patients.


The table shows the reasons for the use of FFB intubation in our 66 study patients. In 10 of 66 patients (15.2%), the airways had been classified preoperatively as Mallampati class IV. In 51 cases (77.3%), the preoperative identification of abnormal anatomic conditions was considered to be a sufficient reason for the patient to be intubated via FFB. Abnormal anatomic conditions included temporomaxillary ankylosis (n = 9), maxillofacial ankylosis (n = 9), cervical spine abnormality (rigid neck; n = 4), thyroid tumor (n = 3), giant goiter (n = 3), laryngeal malformation (n = 3), Le Fort II fractures of the maxilla (n = 3), submandibular abscess (n = 3), parapahryngeal abscess (n = 3), and miscellaneous pathologic conditions (16). Five of the patients (7.6%) presented as emergency cases and had no preoperative evaluation of their airways. These patients required FFB intubation because attempts at direct laryngoscopy during surgery had failed.


Tracheal intubation with FFB is a well-known technique. Proper preanesthetic evaluation of the airway and the patient's head and neck anatomy is necessary to determine whether a patient can be intubated via direct laryngoscopy or if that patient is a better candidate for FFB-guided intubation. (7,12,15,16,20-22) Gentle, fast, and successful tracheal intubation is a particular challenge in patients who have experienced facial and neck trauma (22) and in those with a rigid neck, a large tongue, or morbid obesity; in these patients, nasotracheal intubation with FFB can be performed with topical anesthesia. Special masks and tubes may also be required to properly oxygenate difficult-to-intubate patients. (23-25)

If the Mallampati classification or other preoperative evaluation methods are not possible, a careful assessment of abnormal anatomic conditions of the head and neck is a sufficient basis for choosing FFB-guided intubation, to avoid unnecessary risks to the patient. Failed attempts at direct laryngoscopy may provoke unnecessary trauma to some structures, such as the epiglottis and larynx, and result in postoperative cervical discomfort.

The incidence of failed intubation with a rigid laryngoscope is quite low: 1 in 2,300 attempts. (15) In obstetric patients, a much higher rate of failure has been reported: 1 in 300. (26,27) Nevertheless, endotracheal intubation with FFB must always be considered as a possibility in the operating room and in the intensive care unit. (28) Endotracheal tubes of various sizes may be introduced easily with the aid of FFB. Reports of neurologic injury as a result of tracheal intubations in patients with undiagnosed spinal cord injuries are uncommon, but intubation using FFB in these patients is less dangerous. (22)


In selected cases, the need for intubation with FFB may be anticipated based on abnormal anatomic alterations of the neck, head, and airway, as observed in this study. Nevertheless, the need for preoperative evaluation of the upper airway must be stressed. It is advisable that fiberoptic bronchoscopes and an anesthesiologist or bronchoscopist skilled in the use of FFB be available in all operating suites and intensive care units.


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Eduardo Elizondo, MD; Francisco Navarro, MD, FCCP; Alfredo Perez-Romo, MD; Concepcion Ortega, MD; Heberto Munoz, MD; Raul Cicero, MD, FCCP

From the Pneumology Unit (Dr. Elizondo, Dr. Navarro. Dr. Perez-Romo, and Dr. Ortega) and the Department of Anesthesia (Dr. Munoz), Hospital General de Mexico S.S.: and the Faculty of Medicine, Universidad Nacional Autonoma de Mexico (Dr. Cicero), Mexico City, Mexico.

Reprint requests: Francisco Navarro, MD, Unidad de Neumologia, Hospital General de Mexico, PO Box B-84, Coahuila #5, Mexico, DF 06703. Phone: 011-5255-5004-3857: fax: 011-5255-5282-4771: e-mail: rc1neumo@
Table. Patients in study who underwent endotracheal intubation with
flexible fiberoptic bronchoscopy (N = 66)
                                  Patients       for       Emergency
Preanesthetic evaluation/         intubated   intubation   intubation
abnormal anatomy                   w/ FFB      with FFB     with FFB

Mallampati IV                        10          10
Temporomaxillary ankylosis            9           9
Maxillofacial ankylosis               9           9
Rigid neck                            4           4
Thyroid tumors                        3           2            1
Giant goiter                          3           3
Laryngeal malformation                3           2            1
Le Fort II fracture of maxilla        3           3
Submandibular abscess                 3           3
Parapharyngeal abscess                3           3
Laryngeal synechia                    1           1
Prognathism                           1           1
Micrognathia                          1           1
Laryngeal stenosis                    1           1
Mandibulectomy                        1           1
Posterior larynx                      1           -            1
Parathyroid pseudomyxoma              1           1
Mandibular fracture                   1          --
Macroglossia                          1          --            1
Malignant thymoma                     1           1
Cleidocranial dysostosis              1           1
Mandibular osteomyelitis              1           1
Xiphoscoliosis                        1           1
Carcinoma of the tongue               1           1
Morbid obesity                        1          --            1
Cervical calcification due            1           1
  to Paget's disease

Totals                               66          61            5
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Article Details
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Author:Elizondo, Eduardo; Navarro, Francisco; Perez-Romo, Alfredo; Ortega, Concepcion; Munoz, Heberto; Cice
Publication:Ear, Nose and Throat Journal
Article Type:Clinical report
Geographic Code:1MEX
Date:Nov 1, 2007
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