An Adopted 43-Year-Old With Bad Breath, Dyspnea, Dysphagia

Intraoral infections, including retropharyngeal and parapharyngeal abscesses, pose a potentially life-threatening difficult airway situation. The immediate proximity to the upper airways and potential for rapid progression (even with minor edema or deviation) may result in near-total or complete obstruction, demanding immediate intervention measures and airway stabilization.

In the ideal scenario, an endotracheal or nasotracheal airway should be established in the operating theater under the auspices of the anesthesiology services, with involvement of the otolaryngology or surgical services readily available should the need for a surgical airway become necessary. If these services aren't immediately available, awake intubation should be attempted to optimize success. Furthermore, given the tenuous nature of the patient's stability, and given the potential for rapid progression (as seen in this case), practitioners should be keen on securing the airway sooner than later; if possible, they should discuss with the patient the risk/benefit ratio for an early urgent intubation vs the potential of a later emergent procedure should he or she decompensate.

Numerous pharmacologic agents are available to maximize successful airway control, be it endotracheal, nasotracheal, or otherwise. First-pass success is always the goal; the best environment to maximize these conditions is an adequate degree of patient sedation while still maintaining their respiratory effort and hemodynamics. The best approach should include a combination of dissociative sedatives, anesthetics, and adjunctive agents. Ketamine and etomidate allow for an adequate degree of sedation/dissociation while maintaining respiratory and cardiopulmonary parameters. Benzodiazepines, fentanyl, and dexmedetomidine may be used as well to allow appropriate relaxation on the part of the patient, but with caution, as they affect the respiratory drive and may augment blood pressure and heart rate.

Anesthetics are an important and often underused class of medications that can help maximize first-pass success as well. Several routes of administration are available, including the following:

Topical (in the posterior oropharynx and/or nares);
Nebulized/atomized form; and
Local nerve blocks (eg, glossopharyngeal, superior laryngeal, recurrent laryngeal nerves).

Used alone or in combination, these can offer the patient a great degree of comfort and tolerance during the procedure and maintenance of the tube. Finally, one may consider using adjunctive agents to facilitate intubation; antisialagogues (eg, glycopyrrolate or atropine) help combat excessive secretions and offer good visualization, and steroids (eg, dexamethasone) can help reduce airway edema.

Of note, paralytics may be used very judiciously in these cases, as an edematous incompetent airway that collapses may be disastrous. As with all medications, the practitioner needs to be aware of appropriate dosing regimens, depending on the degree of sedation required, as well as any potential interactions with other agents and the patient's diagnosis and underlying medical conditions.

Numerous approaches are available: direct laryngoscopy, fiber-optics, and intubating bronchoscopes, to mention just a few. The practitioner may choose what they are most comfortable with and be aware of local availability in their facility. A surgical approach must be readily available, should the need for an emergent surgical airway become necessary in the context of a patient who decompensates into the dangerous "can't oxygenate, can't ventilate, can't intubate" scenario.

In this patient, after discussing the case with the otolaryngology and anesthesia services, the decision was made for awake intubation in the ED by anesthesia via endotracheal fiberoptic laryngoscopy, with a combination of racemized epinephrine, dexamethasone and lidocaine, topical lidocaine to the posterior oropharynx, and small aliquots of midazolam with fentanyl for sedation.

After the airway is secured, empiric antibiotics must be initiated immediately. Available antibiotics include beta-lactams, fluoroquinolones, macrolides, tetracyclines, and aminoglycosides. Several beta lactam-resistant strains have recently emerged; multiple alternative agents are readily available.^[9] In the patients who are more significantly ill (as in this case), the intravenous route is obviously preferred.

H influenzae is particularly susceptible to third-generation cephalosporins. In extreme situations, such as secondary to multiple allergies or unavailability of other the antibiotics mentioned, chloramphenicol may be considered. Extra caution is important given chloramphenicol's considerable adverse effects. Steroids may also be given; although they may augment the body's inflammatory response, they have been shown to be beneficial and improve morbidity and mortality. In the presence of abscess formation, standard of care remains incision and drainage. In this case, the otolaryngologist attempted intraoperative drainage of the fluid collection with minimal output.

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