Successful video laryngoscopy-guided intubation in a patient with laryngotracheal disruption

Laryngotracheal disruption resulting from blunt neck trauma, strangulation, or hanging often leads to airway collapse and endotracheal intubation using direct laryngoscope is difficult in such cases. Recently, fiberoptic intubation or emergency tracheostomy are suggested to secure the airway in a patient with laryngotracheal disruption [ , ]. Here, we report a case of laryngotracheal disruption caused by hanging, in which video laryngoscope was helpful for the rapid detection of laryngotracheal disruption and successful endotracheal intubation.

A 64-year-old man with a history of mood disorder, alcoholism, and renal cell carcinoma was found hanging from a vinyl rope. When emergency medical services arrived, the patient had been laid down on the stairs, and the vinyl rope was cut. Since the patient was in asystole, he received cardiopulmonary resuscitation and intravenous administration of adrenaline, and was transferred to the emergency department.

Upon arrival at the emergency department, a return of spontaneous circulation was achieved. The patient was unconscious, and endotracheal intubation was performed using a McGrath video laryngoscope. Vocal cords appeared normal on video laryngoscopy. However, when the video laryngoscope blade lifted the tongue base upward, the vocal cords dislocated upward and the edge of the disrupted trachea was identified ( Fig. 1 ). The position of the video laryngoscope blade was adjusted to minimize dislocation of the vocal cords, and the endotracheal tube was carefully advanced into the trachea through the vocal cords (Video). Endotracheal intubation was performed successfully.

The patient had transverse linear abrasions on the anterior aspect of the neck but no apparent subcutaneous emphysema. Computed tomography of the neck did not reveal subcutaneous emphysema, cervical spine fractures, or fractures of the hyoid bone, thyroid cartilage, or cricoid cartilage. The patient died 10 h after admission.

Video laryngoscopy may be valuable for the diagnosis of laryngotracheal disruption. Previous studies reported that laryngotracheal disruption commonly occurs between cricoid cartilage and first tracheal cartilage [ , ]. Furthermore, 14 of 19 cases of post-traumatic laryngotracheal disruption were completely separated [ ]. Therefore, the postcricoid mucosa should be closely examined when laryngotracheal disruption is suspected. Video laryngoscopy can promptly provide a more panoramic view of the larynx compared to direct laryngoscopy. In comparison to bronchoscopy, video laryngoscopy could be easier and quicker for examination of the larynx. Based on our experience, the brightness and fineness of the display are sufficient for diagnosing laryngotracheal disruption. In addition, it allows sharing of laryngeal observations with other physicians. Some devices can also record the laryngeal observations [ ].

Video laryngoscopy may have advantages over direct laryngoscopy for successful endotracheal intubation. Endotracheal intubation using direct laryngoscopy often fails in patients with laryngotracheal disruption [ , ], as operators would have to lift the tongue base sufficiently to visualize the vocal cords. However, in a patient with laryngotracheal disruption, lifting the tongue base can cause an upward increase in vocal cord dislocation, resulting in failure of the endotracheal tube advancement into the trachea. In contrast, video laryngoscopy uses a camera located on the blade of the device, thereby minimizing the tongue base lifting during endotracheal intubation. Video laryngoscopy provides the real-time images during the advancement of endotracheal tube. If the endotracheal tube cannot advance into the trachea, a gum-elastic bogie should be considered.

In conclusion, video laryngoscopy-guided intubation may be a valuable option for endotracheal intubation in patients with laryngotracheal disruption.

Funding

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Previous presentation

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CRediT authorship contribution statement

Mio Nagata: Writing – original draft. Shunsuke Kudo: Writing – review & editing, Supervision. Motoyasu Nakamura: Visualization, Supervision.