A case of difficult airway ( 一例困难气道）

shenxiu2

52 years old man . No previous  medical problem.
Diagnosed to have carcinoma of the left  maxilla one year ago.
Underwent total left maxillectomy and radiotherapy to the affected areas,completed treatment  7 months ago.
He was using a prosthetic obturator to fill up the cavity left behind by the left maxillectomy.
Later he developed orocutaneous fistula of the left face. The fistula was communicating a defect between the left face and the oral cavity.

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zwwsh

老大能翻译一下不。

麻油

这是一例上颌癌术后及放疗后，面部缺损（瘘管，与口腔相通）

shenxiu2

由于术后放射治疗，只能开口 2CM。
现在拟做瘘管缺损修补。
如何麻醉？

joo0918

气管切开不行么？  纤维支气管镜下清醒插管。

shenxiu2

气管切开不行么？  纤维支气管镜下清醒插管。
joo0918 发表于 2010-6-8 00:27

                               
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If we do not have the fibreoptic bronchoscope , can we avoid tracheostomy?

若我们没有 纤维支气管镜,有没有办法避免气管切开?

shenxiu2

Traditionally we are taught to use inhalational induction for difficult airway, but in this case, we are not able to maintain an  airtight mask seal because of the big leak at the fistula.
There is a large hollow space in the oral cavity after removing the prosthetic  obturator, which may allow us to intubate him , but we would not know( cannot be sure )  until we can visualize the larynx after induction.

传统上我们的教导是:困难气道，用吸入诱导，保持自主呼吸。可是在此个案，我们不能有效的用吸入诱导麻醉，因为有很大的漏洞（瘘管），麻醉气体都漏出来了。

左边的口腔在拿出人造的上颌后，其实有蛮大的空间可以尝试插管。不过还没尝试之前，并不能肯定。

yana

I think it's better to be tracheostomy than others because-----
1] Either oral or nasal intubation, it will interupt  the operation hands on the face ,
2] The anesthetic tube at the surgical field do not be good management by us
   ....and so on


我想最好还是气管切开，因为——
1，无论经口还是经鼻插管麻醉，都将影响面部手术的操作；
2，位处术野的气管导管不好管理....
等等

shenxiu2

The surgeon said that he is not going to operate intraorally. He is going to only operate on the face.
By using a rotation flap from the face (in between the eyebrows),  to cover the defect below the left eyes.

外科医生说他不会在口腔内作手术。他只会在面部动刀。
他会把眉间的一块皮和组织切开，转过来，覆盖在缺损的开口上，补起缺口。

shenxiu2

In this case , we had intubated him orally using size 8 tube.This picture was taken after intubation .( You may notice the endotracheal tube on the right angle of the mouth, and his right eye was closed and taped with transparent tape). He was actually anesthetized , but his left eye was not closed  because of the fistula & distortion of anatomy ( This eye cannot be closed naturally ). we did not tape the left eye because this was the operating field.
在此个案，我们成功用8号气管导管插管。这是插管后的照片。（你可能看到右边嘴角的气管导管，他的右眼也被透明胶布贴上了。)
这照片中的他其实已经在全麻之下了，只是他的左眼还开着，这是因为那个瘘管造成的。（左眼不能自然关上）。我们没有在左眼贴上胶布，因为这是动手术的部位。

shenxiu2

我们用的是土方法。
我们在术前就和病人讨论了气管切开的可能性，并且让他签了知情同意书。
诱导前，准备了喉罩。并且让他拿出了人造上颌。
我们在他的瘘管缺口上覆盖上了纱布和胶布。封了漏气的洞。然后吸入诱导。
麻醉深了，就用喉镜McCoy,看到咽喉声门后，就让另一人静脉注射肌松药司可林，接着插管。

We tried a simple method.
During preanesthetic visit , we discussed with the patient the possibility of the need of tracheostomy. And let him signed the consent for it.
Prior to induction , we got ready laryngeal mask . And we asked him to remove the Obturator.
We used gauze and plaster to cover the defect on the face. So that the leak is  much reduced. Then wen proceeded with inhalational induction.( Sevoflurane)

When the anesthesia is deep enough, we use McCoy laryngoscope to have a look , after visualization of the larynx and the vocal cords, another operator injected the muscle relaxant ( Scoline ) , and intubated him.

943860308

删掉这个图片吧，或隐藏一下 ，每次上论坛都被吓一跳！！！！！！！！！！！！！！！！！！！！！！！！！！！！

toutou

学习了，前辈真高呀，肯定下喉镜插管的时候也比较困难，牙也有缺损~~~

shenxiu2

回复 15# wemychy

这台手术的主刀医生是某国国家癌症中心的主任，头颈外科专家。在他的诊所里进出的很多病人都是这个模样，有些半张面孔都不见了。在还没有作重建手术之前，他们都得带着这种模样过日子。我和他们谈的时候，心里挺佩服他们与癌症奋斗到底的勇气和坚强。

尤其是图中这个病人，他的坦然，和对生命的信心，使我印象深刻佩服。
这些都是有尊严的人，样子不好看，可是有颗令人尊敬的心灵。

The surgeon for this operation was the chief of a  national cancer institute. Many of his patients that walk in and out of his clinic are having similar appearance as this patient. Before they undergo reconstructive surgery , they have to carry on with their lives with this types of faces. When I talked with them , I really saluted their courage and determination in fighting cancer.

The man in this picture especially impressed me with his accepting attitude , and his faith towards life .
These are people with dignity , they may look ugly, but they have respectable souls.

shenxiu2

回复 16# toutou
Surprisingly the laryngoscopy was rather easy , probably because of the ample space inside the mouth after the removal of the prosthesis/ obturator.

喉镜倒是挺容易的，可能是因为把人造上颌取出后，口腔内的空间变大，视野也很好了。