Disposcope endoscope-guided tracheal intubation under slow induction with preserved spontaneous breathing in two patients with giant vocal fold granuloma: two case reports

Although pathologically benign, giant vocal fold granulomas are space-occupying laryngeal lesions capable of causing fatal airway obstruction, posing significant challenges during general anesthesia. Conventional rapid induction with neuromuscular blockade may be associated with loss of spontaneous breathing and a narrow rescue window if airway obstruction worsens, whereas awake intubation is often limited by patient intolerance or contraindications. We report two cases in which slow induction with preserved spontaneous breathing combined with Disposcope endoscope-guided intubation was used as an individualized strategy after awake tracheal intubation was declined. This report does not aim to establish slow induction as a safe, superior, or generally applicable alternative to awake tracheal intubation. Two female patients with giant vocal fold granulomas scheduled for suspension laryngoscopic resection were included. Both exhibited Mallampati classes I-II, normal neck mobility, and preserved spontaneous breathing. Given psychological resistance to awake intubation and lack of cooperation, slow induction general anesthesia was implemented. Anesthesia was induced with sufentanil, propofol, and remifentanil. The Disposcope-guided tracheal intubation was performed under deep sedation, avoiding contact with the granuloma. Anesthesia was maintained with sevoflurane, propofol, dexmedetomidine, and remifentanil, with mechanical ventilation after tracheal intubation. Surgery lasted 15 and 20 minutes, respectively, with uneventful extubation and postoperative recovery. In these two carefully selected patients with giant vocal fold granulomas who declined awake intubation, tracheal intubation under slow induction with preserved spontaneous breathing and Disposcope guidance was completed successfully. The favorable outcomes may have been contributed to the complete management strategy—including favorable routine airway findings, low lesion mobility, careful drug titration, preoxygenation, visual guidance, operator experience, and immediate otolaryngology backup—rather than to slow induction itself. These cases do not provide evidence that slow induction is safe, safer than, or an established alternative to awake tracheal intubation.