Parotid Abscess with Threatened Airway Obstruction- A Case Report

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Parotid Abscess with Threatened Airway
Obstruction- A Case Report

• Dr Subramania Bharathiar Prof and HOD,
• Dr Ponambalam, Dr Lakshmi, Dr Bhaskar

• Dr Jyoti P Rasalkar

• Stanley Medical College, Chennai

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Chief complaints

• 40 yr/male
• C/o painful swelling below left ear and left
  cheek since 3 days.

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History of Presenting Illness

• Patient complained of swelling over left cheek
  and below the left ear of 3 days duration
  gradually progressing in size associated with
  deviation of mouth to opposite side

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• Swelling associated with throbbing pain
• h/o high grade fever ()
• h/o not able to eat/drink/speak
• h/o pus draining from mouth

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Past history

• No h/o HTN/DM/IHD/BA/TB/Epilepsy/drug allergy
• No h/o previous surgeries
• h/o smoking(), alcoholism()

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Investigations

• Hb - 11 gm
• TC 20,000/cumm
• RBS 102 mg/dl
• Blood urea 24 mg/dl
• Serum creatinine 1.2 mg/dl
• Chest X-Ray normal study
• ECG Sinus Tachycardia

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• Neck X-Ray AP large soft tissue shadow below
  left ear
• CT Scan Head and Neck large hypodense lesion
  with irregular ring enhancement involving
  superficial and deep lobes of parotid significant
  edema of surounding tissues causing indentation
  of lateral pharngeal and oral mucosa into
  oropharyx and oral cavity

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Clinical examination

• Patient conscious, oriented
• Temperature-102 degree F
• PR -124/min
• R/R28/min
• BP-110/70 mm hg
• SpO2-97(room air)
• CVS-S1 S2 () no murmurs
• RS- NVBS () no added sounds

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Local examination

• A huge left parotid abscess extending from back
  of left ear to angle of mouth
• From lower margin of left eyelid to lower part
  of neck
• Pus draining out of the mouth

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Airway examination

• Mouth deviated to right,
• Severe trismus with restricted mouth opening
  (inter-incisor gap2cm) and pus draining out of
  the mouth
• Short neck with restricted extention. Swelling
  extending into left side of neck, causing neck
  edema .
• No signs of chest retraction or stridor

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• Case was posted for emergency Incision and
  Drainage of the abscess
• Case was assessed under ASA PS III(E) (Sepsis).

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Anaesthetic plan

• Tracheostomy under local anaesthesia with portex
  cuffed tracheostomy tube
• Genaral anaesthesia with controlled ventilation

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• I V access left forearm with 18 G IV cannula
• Monitor HR, NIBP, SPO2, ECG
• Patient put in supine position with 15 degree
  head up tilt
• Tracheostomy performed by ENT Surgeon under local
  anaesthesia with 7.5mm Portex cuffed tracheostomy
  tube

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• Premedication inj.glyco 0.2 mg i.v
• inj.fentanyl 100 mcg
  i.v
• Preoxygenation 100 O2 -3min
• Induction inj.thiopentone 250 mg
• Maintainance N2OO242
  inj.atracurium 25mg
• halothane 0.5-2

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Intra-Op..

• Procedure Incision and drainage of abscess
• 200 ml pus drained
• Duration of surgery 20 min
• I V fluids 2 pint crystalloids
• HR 110-130/ min
• BP 130/80 -150/90 mm hg
• SpO2 97-98

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• After onset of spontaneous respiration, patient
  was reversed with
• inj.neostigmine 2.5 mg i.v
• inj.glyco 0.4 mg i.v

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Post-operatively,

• Patient concious, oriented, obeys command.
• Reflexes regained muscle power adequate
• PR110/min
• BP120/80 mm Hg
• SpO2 99 on room air
• CVS S1S2 ()
• RS NVBS ()
• Tracheostomy tube was removed after 7 days

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Discussion
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Problems

• 1) Severe trismus
• 2) Protrusion of abscess into the airway
• 3) Facial deformity (edema)
• 4) An inflamed and reactive airway

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Parotid Abscesses And Anaesthetic Challenges

• Parotid abscess often presents with severe
  trismus with mouth opening inadequate for
  intubation
• The abscess itself by protruding into the airway
  can result in obstruction
• Inflammation and edema of the surrounding
  tissues contributes to airway obstruction as also
  facial deformity

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• Good mask seal often not possible and may not be
  adequate for positive pressure ventilation
• Any rupture of abscess can lead to fatal
  aspiration
• If succinylcholine is administered to break the
  trismus, consequent relaxation of pharyngeal
  muscles may lead to upper airway obstruction

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• Any loss of consciousness or interference with
  airway reflexes could result in airway
  obstruction or aspiration
• Laryngospasm is almost always a possibility in
  these reactive airways
• Nasogastric tube placement risky for the same
  reasons

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The Action Plan

• In this situation, an emergency tracheotomy is
  life saving.
• Induction should be delayed until airway has
  been secured (often) with a tracheostomy.

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Tracheostomy

• Surgical airway
• Time required- 3 min
• It is indicated when the risk of loss of the
  airway during attemped tracheal intubation is high

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• Tracheostomy under local anaesthesia is an
  excellent way to secure airway in following
  situations
• 1)patient with an upper airway swellings with a
  distorted pathway for endotracheal intubation
• 2)patient with a bulky friable mass in upper
  airway

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• In these situations, attempts at direct
  laryngoscopy and intubation may result in rupture
  and/or aspiration of pus, blood or material from
  a friable mass

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Alternative Plans

• Fiberoptic oro/nasotracheal intubation under
  topical anaesthesia
• Surgeon can attempt needle aspiration for
  decompression of abscess under LA

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Awake Fiberoptic Intubation

• Considered as Gold-Standard in conditions of
  difficult airway
• Spontaneous breathing continues
• Oxygenation and ventilation maintained
• Intubation easier
• Anatomy and muscle tone preserved
• Phonation as a guide

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Disadvantages

• Skill and expertise needed
• Advancement of ETT into trachea may pull the FOB
  out of trachea
• Forceful advancement should be avoided because it
  may traumatise the larynx
• Vision obscured by secretions or blood and
  interfere with airway evaluation and endotracheal
  intubation

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Contraindications to FOB

1. Lack of adequate time
2. Edema of pharynx or tongue, tracking infection,
   inflammation and hematoma (reduced field of
   vision)
3. Blood/secretions in oral cavity
4. Pharyngeal abscess (risk of rupture while
   railroading of ETT)

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Summary

• Inflammatory masses around upper airway throw a
  combination of a variety of anaesthetic
  challenges and securing an airway safely is the
  cornerstone of management

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Thank You