Airway Management of Granuloma Post Intubation: 2 Cases Report

    

    

    Figure 2: Sessile laryngeal granuloma originating in the right vocal cord with obstruction of the half of the tracheal orifice.
    

Clinical findings: Pre-anesthetic evaluation found a patient ASA 1 in good health, Mallampati III cardiac and respiratory evaluation without abnormality. The obstruction of the glottic lumen posed a problem of the management of the airways, like the first case, necessitating the patient's consent for a possible tracheotomy in case of impossible mask ventilation.

Follow-up and outcome of interventions: After admission to the operating room, checklist of difficult intubation equipment (laryngeal mask, Eshmann guide, armed probe of different size 4-6mm) plus tracheotomy table for emergency airway management.

The anesthetic induction after standard monitoring and fluid replacement through intravenous line with fentanyl 3μg/kg, propofol 3mg/kg, after verification of effective mask ventilation, curarization ensured by rocuronium 0.6mg/kg.

Given the difficulty of airway management, first-line videolaryngoscope (McGrath) used to visualize the tracheal opening and then we noticed a right granuloma almost completely obscuring the tracheal light Intubation is provided by probe n°5.5 army passing finely below the granuloma with bleeding on contact, given the difficulty of glottic exposure in a patient cormack IV intubation is accompanied by mobility of the incisor during intubation.

After verification of an effective ventilation, surgical procedure allowed complete excision. Patient then admitted to post interventional room decurarized by neostigmine and extubated without incident, SPO2 was 97% in ambiant air without dyspnea nor dysphonia, except that the patient losed the two incisor during suspended direct laryngectomy.

Discussion

Orotracheal intubation is a common act in anesthesia and conditon to a prior assessment of ventilation. it’s performed in the majority of cases without incident. the occurrence of complications is frequent associated with difficult intubation.

The earliest report of laryngeal granuloma was submitted by Clausen in 1932 [5], Since that time, it is well known that prolonged endotracheal intubation may result in development of laryngeal granuloma. But laryngeal granuloma caused by short-term intubation has not been reported. We encountered a laryngeal granuloma growing by endotracheal intubation for 4.5h. Furthermore, the otologist declares that patients suffering from laryngogranuloma visit the department every 2 months. The occurrence rate of laryngeal granuloma was reported to be ranging from 0.01% to 3.5% [6]. There are many etiologic factors :the trauma of intubation, infection, the use of oversized tube, excessive cuff pressure in the presence of nitrous oxide, the duration of intubation, and the positioning of endotracheal tube [7-9]. Predisposing factors reinforces age, gender, anatomic character, fragility of the laryngotracheal mucosa, and hyperacidity with gastric reflex; Women are more likely to develop granulomas, as is a patient who is obese, has a short neck, or possesses other congenital anomalies involving the airway [10]. Prevention primarily involves avoiding or eliminating the etiologic factors. To reduce the incidence of the postintubation complications, there are many means: atraumatic intubation under direct vision during laryngoscopy, use of smaller endotracheal tubes, attention to cuff pressure, prevention of excessive flexion or extension of the neck, and the use of muscle relaxants or adequate depth of anesthesia to avoid reflexive movements around the tube [11-13]. Treatment consists of strict voice rest, cessation of smoking, corticosteroids, antibiotics, antacids, and surgical removal under direct laryngoscopy. However, some laryngeal granulomas are highly refractory to standard therapies [14]. For these persistent or recurrent granulomas, repeated excision followed by low-dose irradiation may provide successful resolution [15]. Most anesthesiologists recognize that hoarseness often is a postintubation complication. Few anesthesiologists, however, realize that developed postintubation laryngogranuloma may cause dyspnea that leads to emergency surgical excision. The sign of growing granuloma is hoarseness. Difficult vocalization, dyspnea, and pharyngodynia appear a few weeks or a few months after surgery. Patients should be informed of the risk of laryngogranuloma and its signs and symptoms and should be instructed to visit an otorhinolaryngologist if they experience postintubation hoarseness for more than 1 week.

The recurrence rate of intubation granulomas renders the treatment of these lesions challenging. As we could verify in this review, few studies approach this topic with rigorous methodology and in many the information is incomplete and often the number of patients is small.

Analyzing the studies selected in this review, females (76%) and adults predominate, corroborating the findings of other authors [16]. Even in post-intubation granulomas, gastroesophageal reflux is an important predisposing factor, and its treatment is the main clinical treatment indicated in the studies here listed. Gastro-eosophagial-reflux disease is certainly a deleterious factor to the epithelization of the laryngeal mucosa damaged by intubation [17]. Injuries to the laryngeal mucosa caused by exposure to gastric juice have been described for decadesas well as the benefits of treatment with proton pump inhibitors in improving vocal symptoms and laryngeal lesions in patients with acid laryngitis. Proton pump inhibitors have been advocated in laryngeal granulomas, regardless of the etiology of the lesion [18].

Vocal overuse is another factor predisposing to the formation of post intubation granulomas, as observed in two studies of this review, that included five patients. Exaggerated phonation causes traumatic collision of the vocal folds, resulting in lesions of the arytenoid epithelium and delayed tissue healing [19].

Choosing the ideal treatment for post-intubation granulomas has been a constant challenge for many specialists. Drug treatment alone is lengthy, therefore demotivating. According to Koufman, granuloma resolution with clinical treatment may take from six to eight months. Surgical treatment is faster, but involves anesthetic risks, local scars and recurrence, often being reserved for intractable cases. Even after surgery, clinical treatment is almost always initiated in order to reduce relapses, which can occur in 40-90% [20].

Our observations have raised the problem of managing airways in case of laryngeal obstruction by granuloma, in this case the ideal is the use of jet ventilation for respiratory management or intubation in spontaneous ventilation as described in previous observation while preparing an emergency tracheotomy tray. A case report discrubing a worse scenario of intubation; The patient’s symptoms developed following general anaesthesia for dental extractions. Based on the clinical course of increasing frequency and duration of hoarseness, it was reasonable to presume that she had post-intubation granuloma. In this case, the location of the tumour changed after manual ventilation, becoming partially lodged in the glottis by the positive pressure ventilation. Therefore, ideally, awake or semi-awake intubation should have been performed. In cases with large or malignant tumours that can obstruct the glottis and trachea, tracheotomy can be performed, but the tumour was benign and relatively small in size in this case; therefore, we did not select tracheotomy as an airway management strategy. Also, tracheotomy is contraindicated in cases of laryngeal papilloma caused by human papillomavirus, which could not be ruled out preoperatively in this case [20].

Conclusion

several risk factors are associated with post-intubation tracheal injuries; as we can note the majority of the cases are women with more than 70% in the literature, without also forgetting the inflation pressure of the balloon and as well as the size of the probe, these are modifiable factors simple to manage and which can be useful for a better prognosis.

Author Statements

Competing Interests

authors do not declare any conflict of interest.

Authors Contributions

All the authors participated in this work, read and approved the final version of the manuscript.

References

1. Lambert P, Delorme N. Complications laryngées aiguës de l’intubation translaryngée: revue de la littérature Delorme Service des maladies respiratoires et réanimation respiratoire. Réanimation. 2002; 11: 59-65.
2. Blanc VF, Tremblay NAG. The complication of tracheal intubation: a new classification with a review of the literature. Anesth Analg. 1974; 53: 202-13.
3. Lindholm CE. Prolonged endotracheal intubation. Acta Anesth Scand. 1969; 33: 1-131.
4. Bishop MJ, Weymuller EA, Fink BR. Laryngeal effect of prolonged intubation. Anesth Analg. 1984; 63: 335-42.
5. Clausen RJ. Unusual sequela of tracheal intubation. Proc R Soc Med. 1932; 25: 1507.
6. Balestrieri F, Watson CB. Intubation granuloma. Otolaryngol Clin North Am. 1982; 15:567-79.
7. Feder RJ, Michell MJ. Hyperfunctional, hyperacidic, and intubation granulomas. Arch Otolaryngol. 1984; 110: 582-4.
8. Kastanos N, Miro RE, Perez AM, Mir AX, Vidal AA. Laryngotracheal injury due to endotracheal intubation: Incidence, evolution and predisposing factors. A prospective long-term study. Crit Care Med. 1983; 11: 362-7
9. Ward PH, Zwitman D, Hanson D, Berci G. Contact ulcers and granulomas of the larynx: New insights into their etiology as a basis for more rational treatment. Otolaryngol Head Neck Surg. 1980; 88: 262-9.
10. Blanc V, Tremblay N. The complications of tracheal intubation: A new classification with a review of the literature. Anesth Analg. 1974; 53: 202-13.
11. Bishop M, Weymuller E, Fink B. Laryngeal effects of prolonged intubation. Anesth Analg. 1984; 63: 335-42.
12. Barton R. Medicolegal aspects of intubation granuloma. JAMA. 1958; 166: 1821-3.
13. Snow J, Harano M, Balogh K. Postintubation granuloma of the larynx. Anesth Analg. 1966; 48: 425-8.
14. Harari PM, Blatchford SJ, Coulthard SW, Cassady JR. Intubation granuloma of the larynx: Successful eradication with low-dose radiotherapy. Head Neck. 1991; 13: 230-3.
15. de Lima Pontes PAL, De Biase NG, Gadelha MC. Clinical evolution of laryngeal granulomas: treatment and prognosis. Laryngoscope. 1999; 102: 289-94.
16. Martins RH, Braz JR, Dias NH, Castilho EC, Braz LG, et al. Roarseness after tracheal intubation. Rev Bras Anestesiol. 2006; 56: 189-99.
17. Böttcher A, Mencke T, Zitzmann A, Knecht R, Jowett N, et al. Laryngeal injuries following endotracheal intubation in ENT surgery: predictive value of anatomical scores. Eur Arch Otorhinolaryngol. 2014; 271: 345-52.
18. Roh HJ, Goh EK, Chon KM, Wang SG. Topical inhalant steroid (budesonide, Pulmicort nasal) therapy in intubation granuloma. J Laryngol Otol. 1999; 113: 427-32.
19. Hirano S, Kojima H, Tateya I, Ito J. Fiberoptic laryngeal surgery for vocal process granuloma. Ann Otol Rhinol Laryngol. 2002; 111: 789-93.
20. Derkay CS, Wiatrak B. Recurrent respiratory papillomatosis: a review. Laryngoscope. 2008, 118: 1236-1247.