MODERATOR:DR KHAIRUDDIN

Mr A,58 years old Malay gentleman, retired teacherUnderlying hpt and diabetis mellitus under GP follow upChronic smoker,30 sticks cigarettes /dayHistory of fall from stairs 7 years ago, experienced

shooting pain from buttock to right calve but no muscle weakness

not seek medical treatment Went to traditional massageWorsening for 1 year, shooting pain untill both calves assc.

with numbness right foot, unable perform ‘rukuk’ during prayer due to pain, disturb daily activities

Seek medical treatment ,diagnosis: PID with right sciatica pain ,

under ortho follow upManage with physiotheraphy and analgesic ( gabapentin

300mg od + celebrex 200mg prn)

Physical examinations:alert concious pink, bmi 25 (weight 71kg, height 1.68m)

Back:no deformity, no tenderness, straight leg raise positive on right side,power 3/5 right lower limb, sensory intact

Other systems were unremarkabkeXray lumbosacral:reduced interverttebral

space at t12,l1

Proceed with mri lumbosacral:revealed mixed enhancing solid-cystic intradural lesion at level L4 could be due to an ependymoma with impression intradural lesion L4

Differential: astrocytoma, metastasis spinal mets ? Primary

Referred to neurosurgery for intradural mass

Was seen by neurosurgical with plan for laminectomy L2-L5 and excision of intradural tumour

Refer to anaest clinic

First seen in anaest clinic 23/10/2013, plan operation 10/11/2013

He was walking Underlying chronic smoker, hypertension and

DM with no other comorbidities or complaint Bp 130/75mmhg, hr 79, weight 71kg, height

1.68m, bmi 25.2 Airway: interdental gap > 3fb, malampati 2,

thyromental distance > 4fb, no neck abnormality, normal dentition

Other systemic review were unremarkable Ecg cxr normal Hb 14.1/plt 174/twbc 8 Buse:4.4/136/4.7/99, creat 76Classsified as ASA II

Admit ward 1 day prior to operation Advised to stop smoking To bring antihypertensive & DM medications

to ward Knbm at 2am Tab midazolam 7.5mg on and once ot call Repeat all blood investigation once admitted

to ward Gsh as protocol Case d/w with specialist, for AIBP, ICU back up

He admitted to ward 9/11/2013 to 2ef and again seen for preop assessment

No recent urti/no sob/chest pain/failure symptoms

o/e alert concious pink , TMD> 3fb ,Malamapati III, good neck extension

Lungs clear, cvs s1s2 no murmurs Bp 117/72, hr 82

Knbm 2am Optimised bp, aim < 140/90mmhg Continue antihypertensive drug on morning

of op with sip of clear fluid Start sliding scale once knbm Aim discan 6-10mmol/l Gxm per protocol Gac,AIBP, ICU back up Case d/w anaest specialist:may need icu

back up if anticipate long ot time

Operation done in acc ot Seen patient before push to ot, noted

features of difficult intubation, tmd 2fb, small chin, poor denture

He was lying flat but look uncomfortable, asking for any snoring during sleeping and he admit he was snoring but resolved with positioning,need to sleep 2 pillow, felt more comfortable

No daytime somnolence, apnoea

He were on and off cough, heard like chesty, but no urti .he said the cough was normal like that many years already.

Never admitted due to lungs infection before.

Anticipate difficult intubation-activated for standby difficult intubation devices, bougy, glidescope, procile.suction functioning

Case attempted with 2 specialist, trainee and 2 medical officer

Attach monitoring devices, bp 132/74, hr 74 Spo2 100% under ra ivl functioning well Put patient in 30 degree Preoxygenation given longer with 100% O2 Difficult intubation devices and glidescope

standby Oral suction done

Induced with iv fentanyl 100mcg, profopol 140mg

Able to ventilate but with some difficulties Iv scoline 100mg given Laryngoscopy done, unable to visualised

the epiglottis, seen large mass whitish in colour obstructed the laryngeal inlet

Pass stat to specialist Spo2 maintain 100%

Unable to intubate, obstructed airway Secretion +++ from oral cavity Difficult to ventilate, given o2 100% Start desaturated, proseal inserted, still

difficult to ventilate desat till spo2 34%, patient blue Good head thin chin lift applied Wake up patient No episode of bradycardia or hypotensive

episode during hypoxia episode

After patient had spontaneous breathing, tidal volume increasing slowly, spo2 increased but best under 100% oxygen was 92%

Not tachypnoic After fully awake, explained regarding the

incidence and need for referral on table to ent team for diagnostic airway assessment (ent surgeon just next operation theater)

Refer on table to ent collegue next door

Iv glycopyrulate 200mcg given Prepare for fibreoptic videoscope Left nasal packed with gauze soaked with

coccaine Fibreoptic videoscope attempted by ent

surgeon

Findings: glandular mass at base of tongue Cystic mass > right side of epiglottis

anterior surface Piriform fossa and valleculae look clear Posterior pharyngeal wall are bulky and

inflammed Narrow airway, all tissues oedematous

Operation abandoned Suggest by ent surgeon to get biopsy and

further ent assessment before proceed op in view anticipate difficult intubation next time with possibility of tracheostomy.

Anest plan for next operation to combine ent and neurosurgicalWas plan for ct neck earlyLaryngoscope done by consultant ent next day with the findings same as videoscope, vocal cord moving symmetrical with phonation, no vc mass next dayPatient was discharged home with tca ent clinic 25/11/2013

Patient had no new complaints No voice changes, noisy breathing, sob,

loa/low, urti Laryngoscope done: findings same as

before discharged Cxr clear Explained need for biopsy to confirm the

diagnosis, plan elms+biopsy on 2/12/2013 Refer anaest clinic, 27/11/2013 , admit ward

1/12

Imp: soft tissu mass at base of tongue with cystic epiglottic mass and supraglottic soft tissue mass causing oropharyngeal and hypopharyngeal airways obstruction.

Diff:lymphoma,hypopharyngeal carcinoma with cervical lymphadenopaties

Nil new complaint, alert ,pink Bp 121/67,hr 84 Airway assessment:interdental gap>3fb,

malampati 2, tyromental distance <4fb, poor dentition

Other systemic review were unremarkable Cxr clear, ecg sr, nil ischaemic changes Blood investigations all within normal range

Gac, fibreoptic intubation, icu back upAdvised to stop smokingWas explained high risk for icu admission in

view had airway obstruction, and nature of awake fibreoptic intubation.patient understood and agreed

Case d/w specialist incharge,for awake fibreoptic intubation, icu back up

Elective admitted to ward 6A for elms+biopsy Nil complaints Details airway assessment done in ent clinic flexible endoscopy : no deviated nasal septum, it hypertrophy adenoid 50% enlarged retropalate collapse < 50% retrolingual collapse> 50% during normal

inspiration (lateral collapse)

Lateral pharyngeal wall redundant Base of tongue-redundant tissue(hyperplasia

of base of tongue) Mass at right lingual surface of epigglotis Epiglottic rigid, not easily collapse Aryepiglottic fold/aryhtenoid normal Vestibular fold redundant Present of ? Fatty tissue accumulation Vocal cord normal No mass at true cord Subglottic area clear, no mass No collapsing wall at level of upper trachea

Plan for op as plan next morning with high risk consent and icu back up

Next morning, case not proceed after further detail discussion from anaesthetic and surgeon. Not to risk patient with unindicated tracheostomy by surgeon.

plan to combine with neurosurgical team Discharged home with next operation was

plan combined ent and neurosurgical team on 15/12/2013

Mr A admitted 1/7 before op, classified as ASA III with icu backup, awake fibreoptic intubation

Attended in ot 2 anaesthetics, 2 mo Alert concious, bp 142/92, hr 92,spo2 100%

under RA Difficult intubations trolley standby nearby,

fibreoptic ready

Iv glycopyrulate 200mcg, fentanyl 100mcg given

Nasal pack with cocaine Preoxygenation given Awake fibreoptic intubation done using

armoured size 7 anchored at 26cm succesfully

Spo2 maintain 100% during procedure Iv propofol 120mg, esmeron 30mg given Connected to ventilator tv 425ml, rate 12,

peep 4 Proceed op first with laminectomy L4 and

excision intradural mass at 1200noon

Anaesthesia maintained with TIVA remifentanyl/propofol

Intraop, bp stable Minimal blood loss Op uneventhful Ended neurosurgical op at 1545h, op almost

4 hours

Proceed with DL+biopsy+ excision of epiglottic mass at 1620 after reposition patient from prone to supine

Nil complications during operation.ended case at 1730h, op 1hour 10minutes

Not proceed with tracheostomy, trial of weaning in icu

Neurosurgical:well defined smooth surface, solid and cystic tumour firmly adherent to 2 nerve roots.90% excision of tumour with small part of tumour capsule adherent to nerve root was coagulated and left in-situ

IMP:neurofibromaIntraoperatively monitoring showed 10%

improvement

Ent: mass(retention cyst)arising from tip of epiglottis, broad base, ruptured with cheesy material ++, cystic sac excised with microscissor, redundant mucosa of lateral pharyngeal wall, arytenoid swollen and bulky

IMP: epiglottic retention cyst Plan: for iv dexamethasone 8mg tds 3/7

Admitted icu for weaning Need high sedation post op in view patient

restless Patient haemodinamically stable in icu D1 post op was plan for extubation but

patient apnoe on cpap, done direct videoscope in icu through right nasal cavity which unable to pass through the videoscope

Proceed with glidescope, noted soft tissue swelling surrounding the supraglottic area, erythematous, cannot visualised epiglottis

Was then plan for DL+ Trachy by ent on 17/12/2012-D2 post op

Patient intubated sedated, In ot, attended by 3 anaesthetics

Direct laryngoscope done, noted bilateral enlarged tonsil(almost kissing)distorted anatomy

Glidescope: able to visualize epiglottis and anterior vocal cord, both oedematous

Proceed tracheostomy by ent , uneventhful

Trachea slunted deep, slight deviated to left side

Thyroid enlarged Ishmectomy done, part of thyroid tissue cut,

bleeding secured Direct laryngoscopy-supraglottic region

oedematous, redundant mucosa of pharyngeal wall

Only can visualised tip of epiglottis Unable to access vocal cord due to limited

view

Post tracheostomy, weaning in icu Able maintain spo2> 95% under

tracheventimask, patient alert concious and haemodinamically stable

Discharged to general ward after D1 post tracheostomy, D3 post laminectomy L4+ excision intradural tumour, D3 post direct laryngoscopy+biopsy+ excision epiglottis mass

Throughout ICU stay, nil complications encountered.Hemodinamically stable , able wean ventilator setting,good renal profile, tolerate feeding well, discan well controlled and sepsis parameter static, no documented fever.

Was t/o to 2ef on 18/12/2013 Under neurosurgical and ent reviews He was well, on regular physiotheraphy

and bed rest On regular tracheostomy suction Tracheostomy off on 6/1/2014 He was able to walk without aided Discharged home 7/1/2014with tca ent

and neurosurgical Hpe result still pending