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

Chief complaints

40 yr/maleC/o painful swelling

below left ear and left cheek since 3 days.

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

Swelling associated with throbbing pain

h/o high grade fever (+) h/o not able to eat/drink/speak h/o pus draining from mouth

Past history

No h/o HTN/DM/IHD/BA/TB/Epilepsy/drug allergy

No h/o previous surgeries h/o smoking(+), alcoholism(+)

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

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

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

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

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

Case was posted for emergency Incision and Drainage of the abscess

Case was assessed under ASA PS III(E) (Sepsis).

Anaesthetic plan Tracheostomy

under local anaesthesia with portex cuffed tracheostomy tube

Genaral anaesthesia with controlled ventilation

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

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 %

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%

After onset of spontaneous respiration, patient was reversed with

inj.neostigmine 2.5 mg i.v +

inj.glyco 0.4 mg i.v

Patient concious, oriented, obeys command.Reflexes regained; muscle power adequatePR:110/minBP:120/80 mm HgSpO2: 99% on room airCVS: S1S2 (+)RS: NVBS (+)Tracheostomy tube was removed after 7 days

Post-operatively,

Discussion

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

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

Parotid Abscesses And Anaesthetic Challenges

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

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

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.

Tracheostomy Surgical airway Time required- 3 min It is indicated when the risk of loss of

the airway during attemped tracheal intubation is high

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

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

Alternative Plans Fiberoptic oro/nasotracheal intubation

under topical anaesthesia Surgeon can attempt needle

aspiration for decompression of abscess under LA

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

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

Contraindications to FOB

1. Lack of adequate time2. Edema of pharynx or tongue,

tracking infection, inflammation and hematoma (reduced field of vision)

3. Blood/secretions in oral cavity4. Pharyngeal abscess (risk of rupture

while railroading of ETT)

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