Case Report

A 25-year-old female with history of shellfish allergy presented to the emergency department (ED) via ambulance with the complaint of difficulty breathing. The patient was previously at dinner when she became acutely short of breath and had difficulty speaking.

On arrival to the scene, EMS noted a woman in respiratory distress, sitting with her hands on her knees and leaning forward. She had a muffled voice and difficulty with phonation. Vitals on scene included HR 112, blood pressure 130/82, and 99 percent oxygen saturation on room air. EMS placed the patient on nasal cannula for comfort and brought her to the ED. On arrival to the emergency department, she was sitting in a tripod position, unable to phonate with inspiratory stridor, and spitting saliva into an emesis basin. Vitals revealed that she was afebrile, mild tachycardia of 115 beats per minute, tachypnea, BP 120/80, and 100 percent oxygen saturation on room air. As she could not phonate, the patient was only able to shake and nod her head to questions. Per history, it was determined that her symptoms had started two days prior, but acutely worsened after eating “surf and turf” for dinner prior to arrival. She endorsed inability to speak, dysphagia, odynophagia, and shortness of breath. She reported a similar prior episode but not as severe as her current presentation. She denied rash, nausea, vomiting, chest pain, choking sensation, eating food with bones, family history of facial or tongue swelling, or taking any medications at home including angiotensin converting enzyme inhibitors or angiotensin receptor blockers.

Physical exam revealed a clear oropharynx with no appreciable lesion, edema, or uvular deviation. Palpation of her neck revealed fullness without induration or erythema. She had equal, clear breath sounds bilaterally with no wheezing. Cardiovascular exam was without pathologic finding. Patient had no appreciable rash.

Initial Management

Intravenous access was obtained and equipment for difficult airway management was brought to the bedside. Anesthesia and otolaryngology were emergently paged to the department. Intramuscular epinephrine as well as intravenous methylprednisolone, diphenhydramine, and famotidine were administered. A lactated ringers bolus was started. As her oxygen saturation was normal, it was felt that a surgical airway was not immediately indicated. Anesthesia arrived and prepared for fiber-optic laryngoscopy, with a working diagnosis of likely angioedema given her shellfish allergy and having consumed seafood. Prior to initiation of this procedure, the patient began to close her eyes, and required repeat stimulation to maintain alertness. She was kept upright and awake, with nebulized lidocaine as the only pre-treatment measure.

As the scope was inserted, there was no edema at the uvula or posterior oropharynx and no lesion. When progressed further, the scope passed the base of the tongue to expose a large lesion protruding into the airway with near-complete occlusion. The scope, pre-loaded with a small-caliber endotracheal tube, could not be passed around the lesion for intubation. The glottis and epiglottis could not be visualized. There were no signs of bleeding, but copious secretions made complete visualization of the lesion difficult. With a failed fiber-optic intubation, we prepared to perform an emergency surgical airway.

However, the patient continued to oxygenate and ventilate well. The lesion seen with the fiber-optic scope did not appear to be native tissue. It was gray, poorly circumscribed, and avascular. There was concern for a foreign body, though a large pseudomembrane, abscess, and laryngeal mass were also considered. With foreign body now as the leading diagnosis, the patient was kept upright and video laryngoscopy was employed to try and visualize the obstruction via a face-to-face or “tomahawk” approach.

It Wasn’t the Surf, It Was the Turf

After laryngoscope insertion, the lesion was clearly visualized. Magill forceps were quickly acquired to remove a large piece of masticated food. When removed, the food bolus was found to be directly superior to the epiglottis in the supraglottic region. The patient had immediate relief of symptoms and began speaking in a clear voice. Fiberoptic laryngoscopy was repeated, confirming no further foreign body, bleeding, or other pathology.

Figure 1: When removed, the food bolus was found to be directly superior to the epiglottis in the supraglottic region. (Click to enlarge.)

The patient was unaware of any aspiration and believed her symptoms were due to an allergic reaction to the seafood she was eating. After removal of the foreign body, she was asymptomatic, tolerating food and drink. She was observed for several hours with a chest X-ray showing no pulmonary edema or aspiration pneumonitis/pneumonia.

The Tomahawk Approach to Airway Management

Face-to-face intubation, commonly referred to as tomahawk or axe intubation, is a difficult airway intervention utilized in pre-hospital, emergency department, inpatient, and operating room settings.^2,3,4,5 Patients with pulmonary edema, significant spine pathology, obesity, etc. may not be able to tolerate laying supine.^4,6,8 This technique is valuable as it allows glottic visualization without placing patients in a supine position. As these patients are commonly seen in the emergency department, tomahawk intubation is an extremely useful technique to consider when dealing with a difficult airway.

To begin, the patient is left in an upright position. Standard pre-oxygenation and preintubation preparation are performed. The physician then approaches the patient face-to-face. As opposed to traditional intubation, the laryngoscope is held in the right hand and the endotracheal tube (ETT) is held in the left. This is to prevent crossing of arms while attempting to pass the ETT. The laryngoscope is held with the curved blade superior to the handle, resembling how one would hold a pickaxe (or tomahawk). The blade is then carefully inserted into the oral cavity and progressed posteriorly. During this progression, gentle traction is applied to the handle, thrusting the mandible anteriorly. Laryngoscope manipulation should be similar to that of supine intubation, avoiding “rocking” at wrist, and being cognizant of dentition. One the epiglottis and vallecula are visualized, the ETT is progressed with the left hand until the ETT is just superior to the vocal folds. At this point, the physician may intubate and immediately start sedation. Alternatively, if it is too challenging to pass ETT through vocal cords, a sedative and paralytic agent can be administered immediately before advancing the ETT. It should take seconds to pass the ETT once properly positioned, making it safer to administer medications that decrease respiratory drive.

There are several special considerations while performing a tomahawk intubation. It is crucial to have additional airway specialists at bedside, if available. Identifying anatomy and preparing equipment for rapid cricothyrotomy should also be a priority. The patients that benefit most from tomahawk intubation are also most dependent on an increased respiratory drive to maintain ventilation and oxygenation. Agents that minimally effect respiratory drive, such as ketamine or dexmedetomidine, may be preferred.^9,10 Glycopyrrolate has been used to help minimize airway secretions.³ A video laryngoscope is the preferred tool for glottic visualization. While a standard, direct laryngoscope can be used, it is much more difficult. If only a direct laryngoscope is available, a two-operator technique can be used. In this case, one operator inserts and manipulates the laryngoscope. The second operator used a flexible laryngoscope with a pre-loaded ETT to visualize the glottis and pass the ETT. If additional help is available, having a team member provide jaw thrust or tracheal pressure may provide better visualization.

Tomahawk intubation is an effective alternate approach to airway management in patients that cannot assume a supine position. While studies are limited, there are encouraging findings that tomahawk intubation is easier to learn than supine intubation, and both techniques have similar time to intubation.^2,7 When managing UAO, consider tomahawk intubation to secure a difficult airway.

Dr. Yavorsky is an attending physician at MetroHealth Medical Center in Cleveland, Ohio.

Dr. Glauser is professor of emergency medicine at Case Western Reserve University at MetroHealth Cleveland Clinic in Cleveland, Ohio.

References

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