Parotid Abscess with Threatened Airway Obstruction- A Case Report

1. Parotid Abscess with Threatened Airway Obstruction- A Case Report Dr Jyoti P Rasalkar Stanley Medical College, Chennai Dr Subramania Bharathiar –Prof and HOD, Dr Ponambalam, Dr Lakshmi, Dr Bhaskar

2. 40 yr/male C/o painful swelling below left ear and left cheek since 3 days. Chief complaints

3. 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

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

5. Past history No h/o HTN/DM/IHD/BA/TB/Epilepsy/drug allergy No h/o previous surgeries h/o smoking(+), alcoholism(+)

6. 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

7. 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

8. Clinical examination • Patient conscious, oriented • Temperature-102 degree F • PR -124/min • R/R:28/min • BP-110/70 mm hg • SpO2-97%(room air) • CVS-S1 S2 (+) no murmurs • RS- NVBS (+) no added sounds

9. 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

10. Airway examination Mouth deviated to right, Severe trismus with restricted mouth opening (inter-incisor gap:2cm) 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

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

12. Tracheostomy under local anaesthesia with portex cuffed tracheostomy tube Genaral anaesthesia with controlled ventilation Anaesthetic plan

13. 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

14. Premedication: inj.glyco 0.2 mg i.v+ inj.fentanyl 100 mcg i.v Preoxygenation: 100% O2 -3min Induction: – inj.thiopentone 250 mg Maintainance: N2O:O2:4:2 +inj.atracurium 25mg +halothane 0.5-2 %

15. 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%

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

17. Post-operatively, • Patient concious, oriented, obeys command. • Reflexes regained; muscle power adequate • PR:110/min • BP:120/80 mm Hg • SpO2: 99% on room air • CVS: S1S2 (+) • RS: NVBS (+) Tracheostomy tube was removed after 7 days

18. Discussion

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

20. 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

21. 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

22. 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

23. 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.

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

25. 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

26. 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

27. Alternative Plans Fiberoptic oro/nasotracheal intubation under topical anaesthesia Surgeon can attempt needle aspiration for decompression of abscess under LA

28. 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

29. 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

30. Contraindications to FOB • Lack of adequate time • Edema of pharynx or tongue, tracking infection, inflammation and hematoma (reduced field of vision) • Blood/secretions in oral cavity • Pharyngeal abscess (risk of rupture while railroading of ETT)

31. 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

32. Thank You