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Arteriovenous (AV) malformations of the face are rare presentations. Endovascular coiling is one of the treatment modalities. We report a case of a 65-year-old lady who presented with a large AV malformation of the face located around the nasal bride and alae nasae posted for coiling under general anesthesia. Anesthetic management of the case was a challenge as it was an anticipated difficult airway situation. Furthermore, any pressure on the swelling can lead to rupture and hemorrhage as the skin above swelling was unhealthy. There was difficulty in mask ventilation both with larger- and smaller-sized facial masks including Rendell-Baker-Soucek mask. Supraglottic airway device had to be inserted as a rescue measure. After getting effective ventilation, muscle relaxants were supplemented, and trachea was intubated. While intubating the axis of the laryngoscope had to be maintained on the right side to avoid pressure on the swelling as it could traumatize the malformation. The procedure went on uneventful. The patient was extubated fully awake.
Vascular malformations are rare anomalies composing of inappropriately connected vessels. They can arise from any part of the body. They include arteriovenous (AV) malformations, lymphatic, capillary, and venous malformations. Over a period, vascular malformation continues to increase in size. This can cause the destruction of local tissue leading to massive hemorrhage.
Here, we report a case of AV malformation of the face with the risk of impending rupture. The procedure was done in the periphery (Cath Laboratory) where the availability of anesthesia personnel and equipment's were less. It was an anticipated difficult mask ventilation and intubation situation where I-Gel was the sole equipment utilized for rescuing the airway.
A 65-year-old female weighing around 40 kg presented with swelling of the face, over the nasal bridge [Figure 1]. The mass was progressively increasing in size. The angiogram showed AV malformation which was partially thrombosed and calcified. The patient was planned for embolization of the malformation, under general anesthesia. We were informed to be careful while anesthetizing the patient as the swelling was fragile and there was a risk of rupture.
The preanesthetic evaluation was done. She was a diabetic and hypertensive on treatment and well controlled. On the evaluation, there was a swelling on the face which measured around 7 cm × 7 cm in size, adjoining the left medial canthus of eyes, extending to the nasal bridge, and alae nasae [Figure 2]. There were cracks and ooze from the surface. It was also observed that swelling could come in the way of direct laryngoscopy. Mouth opening was adequate, and Mallampati was Class 2. Neck extension was adequate. Investigations were normal. The patient was optimized and kept nil per orally for 8 h. Cath Laboratory was prepared with difficult airway cart including flexible fiberoptic scope and equipment for emergency cricothyrotomy. Our plan was to try normal intubation.
On the day of the procedure, the patient was shifted onto the table. Wide bore cannula was secured, and monitors were connected. Premedication was done with 1 mg midazolam and 50 μg fentanyl. Preoxygenation was tried with size 5 face mask by gently keeping the mask above the face to give oxygen enriched air, taking care not to pressurize on the swelling. Induction was done with 50 mg propofol. Mask ventilation was tried with size 5 face mask, with the view of taking the swelling inside the mask, but the swelling was too big to be included. Then, size 1 face mask and Rendell-Baker-Soucek (RBS) mask were used just to cover the mouth, but we failed to get effective ventilation with both masks as the swelling was coming in the way. Next option was to introduce size 3 I-Gel. We could get effective ventilation with I-Gel. Succinylcholine 50 mg was given. Direct laryngoscopy was done through the right side carefully not to press on the swelling, trying to keep the axis of scope handle on the right side. After creating enough space for intubation, the trachea was intubated with size 7.5 mm cuffed oral endotracheal tube. Bilateral air entry was checked, and the tube was fixed. The patient was maintained with oxygen and nitrous oxide. Atracurium boluses were given as muscle relaxant. Intraoperative period was uneventful. After the procedure, the patient was extubated fully awake.
AV malformation can be congenital or traumatic. Extracranial sites of this malformation include the face, oral cavity, limbs, etc. It can be diagnosed clinically or by radiological methods [Figure 3]. They are high-flow anomalies that shunt blood from arteries to veins. They may not be evident at birth but eventually they grow into big size. They are aggressive lesions that can infiltrate on surrounding tissue. Treatment modalities include sclerotherapy, embolization, or surgical methods. Sclerotherapy is usually used for low-flow malformations whereas for high-output malformations; embolization is advocated.
Coil embolization involves the catheterization of femoral artery and deposition of coils in the angiomatous vessel. This can reduce the flow velocity of blood in the vessels and aids in the formation of thrombus. This can block the risk of rupture.
Swelling arising from the nose extending to the area of mouth is a challenge to anesthesiologists as it can give rise to can’t intubate can’t ventilate situation. The risk was more as the swelling was fragile and any pressure on the swelling could rupture the malformation. Other difficulties include the carrying out a case of difficult airway in an unfamiliar condition outside the operation theater (OT).
In this case, we tried to do mask ventilation with a larger size face mask, size 5 as this technique was described by few authors. We were unable to acquire adequate mask ventilation.
Anesthesia could also be induced with 8% sevoflurane in oxygen and ventilation could be tried with RBS mask kept over patients mouth with lips pursed so that the nasal swelling can be excluded from the mask. After achieving adequate ventilation and deepening the plane with intravenous anesthetics, laryngoscopy can be tried. In our case, we tried this technique but was not successful in ventilating the patient.
Next option was to push in an I-Gel. Ventilation was possible with I-Gel. Direct laryngoscopy was done with the scope handle directed to the right side avoiding pressure on the swelling. Intubation was successful in the first attempt.
One limitation was that we could have tried awake fiberoptic for intubation as it was an anticipated difficult airway situation. However, it was difficult to convince the patient for an awake semi-invasive procedure as the patient was not much cooperative.
Other methods of ventilation reported include the usage of a proper sized nasopharyngeal airway and connecting it to anesthesia circuit via connector. After deepening the plane of anesthesia with sevoflurane and also with small doses of intravenous agents, try to ventilate by closing the opposite nostril, and mouth. Once the adequate depth is achieved try to do a direct laryngoscopy and intubate the trachea. In this case, we were little apprehensive in using a nasopharyngeal airway as it can traumatize the nasal cavity which was near the malformation.
Supraglottic airway devices have always been a choice in cases of the difficult airway. They are used in cases of difficult mask ventilation and also used in cases of difficult intubation. Laryngeal mask airway (LMA) has a prime role as rescue airway device in difficult airway algorithm. They can also be used as a device for maintaining the airway in surgical procedures and as a conduit for intubation including fiberoptic intubation.
In a study comparing the insertion of LMA and I-Gel after simulating difficult airway with reduced neck extension and limited mouth opening, it was found that both devices were equally effective for emergency airway management. Hence, I-Gel is an effective, alternative to LMA in difficult airway management.
Other methods of ventilation include esophageal tracheal combitube and transtracheal jet ventilation in cases of emergency. However, securing airway by cricothyrotomy requires expertise. Other methods of intubation such as awake fiberoptic and retrograde intubation can also be tried.
This was a case of difficult airway which was managed effectively with a supraglottic airway device. I-Gel is simple and cost-effective equipment that can be used even without expertise. It can be used in an emergency situation and should be always available in OT complex.
Providing anesthesia care outside OT is a situation where anesthesiologists are not acquainted with. It becomes more challenging if it is a case of the difficult airway. Meticulous preparation of the procedure room with difficult airway cart and effort from anesthesiologists to face any crises situation are inevitable in the management of such cases. Thus the take home message is that I Gel can be used as an alternative to face mask for ventilation, in anatomically normal airways but are compromised by facial swellings.
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There are no conflicts of interest.