Awake intubation with bronchial blocker in a patient undergoing robotic thymectomy: A case report of challenging airway management

Dear Editor, A ‘difficult airway’ as defined by the American Society of Anesthesiologists (ASA) practice guidelines, is a clinical situation in which a trained anaesthesia provider experiences anticipated or unanticipated difficulty or failure with one or more of the following: facemask or supraglottic airway ventilation, laryngoscopy, tracheal intubation, or extubation. 1 An 81-year-old male patient was referred for surgical management of a fluorodeoxy-glucose-avid anterior mediastinal mass (2 cm) identified incidentally on positron emission tomography scan during staging for recently diagnosed prostate cancer. His past medical history included hypertension, osteoarthritis, previous cholecystectomy, and renal calculi. Airway examination revealed Mallampati grade II, thyromental distance >6 cm, mouth opening >3 cm, limited neck extension, and inability to protrude the jaw. Lung function tests showed a forced expiratory volume in one second of 110% and a transfer factor of the lung for carbon monoxide of 96%. He was initially listed for robotic-assisted thoracoscopic thymectomy. On the day of surgery, induction was done using total intravenous anaesthesia using propofol and remifentanil and muscle relaxation was achieved using rocuronium. At the induction of anaesthesia, airway management proved difficult with repeated failed intubation attempts despite direct and video laryngoscopy (Cormack–Lehane grade III), bougie assistance, and fibreoptic bronchoscopy through a supraglottic airway Figure 1. The procedure was subsequently abandoned, and the patient was safely reversed and recovered. Figure 1: The steps followed during unanticipated difficult intubation situation. DLT: Double lumen tube; ETT: Endotracheal tube; MRI: Magnetic resonance imaging; ENT: Ear, nose, throatFollowing this, he was referred to the otohinolaryngology (ENT) department. On further evaluation, he reported a 6-month history of intermittent hoarseness with episodic complete voice recovery. Examination by the ENT consultant demonstrated a retroflexed epiglottis with mobile vocal cords closing normally. No vocal cord lesions, swelling, erythema, or haematoma were identified. A slight asymmetry was noted in the left pyriform sinus, which appeared bulkier and more pale compared to the right, but with no malignant features. Magnetic resonance imaging of the neck with contrast confirmed a benign-appearing T2 hyperintense focus in the left vallecula, likely representing a cyst, with no evidence of pyriform fossa or vallecular malignancy Figure 2a and b. Additionally, a known left thyroid lobe cyst had increased in size to 6 cm craniocaudal, without causing tracheal deviation or compression. Figure 2: (a) MRI neck showing vallecullar cyst. (b) Image showing the left thyroid lobe and nodule in the left thyroid lobe. (c) Glottic view during fibreoptic bronchoscopy. MRI: Magnetic resonance imagingThe case was subsequently reviewed at a multi-disciplinary team meeting involving ENT, thoracic surgery, and anaesthesia. A joint surgical plan was made: Awake fibreoptic intubation attempt with airway topicalisation, permitting passage of an adequately sized single-lumen endotracheal tube (ETT) for lung isolation via bronchial blocker. Awake tracheostomy under local anaesthesia, followed by the procedure with lung isolation achieved via a bronchial blocker through the tracheostomy. If lung isolation could not be achieved via a bronchial blocker, sternotomy was the last resource. The patient agreed to all options, and subsequently, written consent was obtained. On the day of surgery, remifentanil sedation (0. 06 μg/kg/min) was initiated and awake fibreoptic intubation with topical lignocaine using ‘spray as you go’ technique was successfully achieved with 8. 0 mm ETT. Oxygenation was maintained using high-flow nasal oxygen using a fraction of inspired oxygen (FiO2) of 60%. Figure 2c shows the glottic view during fibreoptic bronchoscopy. Anaesthesia was induced with total intravenous anaesthesia (propofol and remifentanil), and left lung isolation was facilitated with a bronchial blocker Video 1. The procedure was completed successfully, and the patient was extubated at the end of surgery and transferred to the post-operative care unit for monitoring. "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 1. ", "caption": "", "object-id": {"pub-id-type": "doi", "id": "", "pub-id-type": "other", "content-type": "media-stream-id", "id": "1ᵧybt9qnl", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} This case highlights that adherence to ASA difficult airway algorithm principles—avoiding repeated traumatic attempts and prioritising oxygenation—is the key to a safe outcome. 2 Although our patient’s vallecular cyst was incidentally detected after the initial failed intubation, its presence likely contributed to the poor glottic view and unexpected airway difficulty. Vallecular cysts can distort supraglottic anatomy by displacing the epiglottis posteriorly, obscuring the glottic opening and making direct or video laryngoscopy challenging. 3 Limited neck extension, a vallecular cyst, and loss of muscle tone after induction likely contributed to the difficult airway. This case highlights that even with apparently normal airway assessments, unanticipated anatomic variations can cause significant intubation difficulty. A structured, algorithm-based approach, early recognition of failure, and multi-disciplinary planning are vital. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Author contributions JR has contributed by literature search, manuscript writing, editing, review and approval. GS was involved in concepts, manuscript writing, editing, review and approval. Disclosure of use of artificial intelligence (AI) -assistive or generative tools An AI-based tool was used for grammar checking. Declaration of use of permitted tools Nil Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.