Break through cases

Case 1

A 75-year-old male patient presented with oro-cuatenous fistula after undergoing wide excision with modified radical neck dissection, pectoralis muscle musculocutaneous (PMMC) flap reconstruction and tracheostomy for carcinoma of the tongue. He was assigned for elective secondary suturing. Patient had bilateral PMMC flap reconstruction for carcinoma of tongue.
The patient's airway examination revealed that he was edentulous, and had restricted neck movements due to bilateral PMMC flap reconstruction; the tongue was sutured to the left inner side of the cheek, with distorted oral anatomy.
Due to the patient's difficult airway and difficult ventilation, an awake fiberoptic intubation was planned, as well as topicalization of nasal and oral mucosa with local anaesthetic. Following adequate motor recovery and oral suctioning, the patient was extubated.
Following extubation, the patient had difficulty in breathing and there was a drop in oxygen saturation. The patient was re- intubated on an emergency basis. The re- intubation was attempted with fiberoptic bronchoscope. Due to loss of tone and airway edema, the fiberoptic bronchoscopy was not adequate for visualizing the glottis. A combined technique, using videolarygoscope to guide the fiberoptic was deviced and used to intubate the trachea as a life- saving measure
Hence, the patient’s airway was secured. The patient was electively ventilated and anti- edema measures were instituted for 24 hours in the intensive care unit before being extubated and transferred to the post-operative ward. Extubation was done with due precautions and preparation for reintubation.