The management of laryngeal and subglottic stenosis
Editor—We read with interest the article by Cook and colleagues1 discussing the management of the airway in a patient with a large airway tumour. Laser debulking or resection is commonly used in our hospital for the definitive management of airway tumours. We previously used trans-tracheal jet ventilation for some of these cases but our practice has now changed to use a supraglottic approach with a jet ventilation catheter passed through the cords. The external diameter of the catheter is 3 mm, it is laser proof and stiffened so that it does not ‘whip’ with the large pressures used with jet ventilation. Many of these tumours have extensive submucosal spread, and although may look macroscopically normal when viewed with a fibreoptic laryngoscope, may be involved with the primary tumour and still cause seeding. It also decreases the risk of bleeding resulting from the trans-tracheal insertion and of barotrauma with catheter displacement. It may also be worth considering using a small microlaryngeal tube, for example, size 4 (external diameter 5.5 mm), and providing a secure definitive airway. Haemorrhage during laser resection into an airway that is not protected with a cuffed tracheal tube, may be more of a risk than the small chance of an airway fire due to using a nonlaser proof tube.J. H. Low*
R. Smith
Derby, UK
*E-mail: james.low{at}derbyhospitals.nhs.uk
Editor—I would like to express my compliments to Dr Tim Cook and colleagues1 for their interesting case report, that, in a very complete and rational approach, showed the optimal use of ProSeal LMA
in cases of fibreoptic guided airway management. ENT, in particular, offers a variety of occasions when more judicious, but not more complicated, work can be attempted for better results. First, the importance of discussing the case with surgeons. Second, the risk of manipulating a narrow and symptomatic airway. In this case report, the tumour was not seen from the laryngeal inlet but it caused hoarseness and displaced anatomic structures. So I would ask Dr Cook and colleagues to clarify their position regarding a safe approach for laryngeal tumours and specifically to surgical tracheostomy with sedated, but spontaneously breathing patients. My personal point and contribution deals with the possible use of a combined technique of LMA and fibrescopy in situ at the insertion or a combined technique of Glidescope and fibrescopy, that I have carried out in three spontaneously breathing ENT cases (unpublished data).
D. Cattano
St Louis, MO, USA
E-mail: cattanod{at}wastl.edu
Editor—I thank both Drs Low and Smith, and Dr Cattano for their comments. I appreciate the advice of Drs Low and Smith on these difficult cases. We agree with this principle and are also hoping to move to increased use of supraglottic catheters where possible—once we have purchased a suitable jet ventilator to replace hand-held jet ventilation.
Law and Smith also suggest that it may be appropriate to use a nonlaser-safe tube during laser resection, suggesting that the risk of airway fire is acceptable when compared with the risk of airway bleeding from cricothyroidotomy. I have not seen these risks quantified, but airway fire is a life-threatening disaster, while the minor bleeding as a result of a tracheal cannulae is likely to be inconvenient at worst. My ‘unquantified analysis’ would be that this is not wise.
Regarding the case we reported, the extent of narrowing of the airway by tumour would have made placing a supraglottic catheter potentially dangerous, because of the risk of obstructing the airway, with the consequent risk of barotrauma during ventilation. I do not think a microlaryngeal tube could have been passed, and the opinion of the surgeons was that they could not perform the surgery with this in place. As a result our options were rather limited!
I also thank Dr Cattano for his comments. Unfortunately I do not have experience of anaesthetizing patients with laryngeal tumours for ‘sedated tracheostomy’. Dr Cattano suggests the use of a dedicated airway to allow fibrescopy during the procedure. While we have used this technique, with the ProSeal LMA, for percutaneous tracheostomy in approximately 80 cases in our intensive care,2 these were in anaesthetized and paralysed patients. I do not have experience of this technique during sedation and spontaneous ventilation. My only comments would be that the technique is more suited to controlled ventilation (the fibrescope is stimulating to the airway and the fibrescope considerably narrows the airway orifice), and I believe a device through which one can pass a fibrescope and so view the trachea, is likely to be more useful than the C-trach which only offers a view above the vocal cords.
T. Cook*
Bath, UK
*E-mail: timcook{at}ukgateway.net
Footnotes
LMA® is the property of Intavent Ltd. 
*Declaration of interest. Dr Cook has been paid by Intavent Orthofix and the LMA company, both manufactures of laryngeal mask airways, for lecturing.
References
1 Cook TM, Asif M, Sim R, Waldron J. Use of a ProSealTM laryngeal mask airway and a Ravussin cricothyroidotomy needle in the management of laryngeal and subglottic stenosis causing upper airway obstruction. Br J Anaesth 2005; 95:554–7
2 Craven R, Laver S, Cook TM, Nolan JP. Use of the Proseal LMA facilitates percutaneous tracheostomy. Can J Anaesth 2003; 50:718–20[Web of Science][Medline]
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