Case Report: Difficult Airway in the Dental Office
Hi, my name is Dr. Steve Yun, and I am a board-certified dental anesthesiologist in Southern California.
Recently I took care of a young woman in her 20s who needed extensive dental rehabilitation. She had severe cerebral palsy, was very small for her age (height = 4 ft ; weight = 62 lbs), and was not able to cooperate with any dental procedure. Her mouth opening was extremely limited (less than 1.5 inches). She had a history of cleft palate/lip repair. In addition, the dentist's office reported that during her last surgery at the local children's hospital, they had difficulty securing her airway.
On my physical exam, the patient was indeed very small for her age, and she would not allow me to examine her airway in detail. Based on what I could visualize, her airway certainly appeared difficult (see photo). Patients with difficult airways can still be anesthetized safely in the office setting, but it is prudent to first consult an experienced anesthesiologist and even then, extreme caution must be exercised.
Under anesthesia, a patient's breathing can stop or be obstructed due to the sedative effects of the anesthesia drugs. To counter this, anesthesiologists will often secure and control the airway with a breathing tube. In this way, the patient can be safely asleep under anesthesia with their breathing monitored in a controlled, secured manner. . In this case, I was able to place a breathing tube and smoothly secure the patient's airway utilizing these principles:
1. In the office setting, I try to avoid the use of muscle relaxants. In this way, the patient retains their own ability to maintain spontaneous ventilation.
2. I have explicit back-up plans in case my original plan for securing the airway is unsuccessful. In fact, I have Plan B, C, and D ready to go. This includes using the latest technology, a video laryngoscope (an instrument that allows me to see inside the airway of even the most difficult patients.)
3. If my back-up plans do not work, I am not afraid to cancel the procedure. If I cannot secure the airway in an efficient, safe manner, then I quickly terminate the anesthetic and allow the patient to wake up safely. Sometimes the best course of action is to take no further action.
Many dental anesthesia disasters could be avoided if the dental practitioner respects the difficult airway and obtains an anesthesia consultation for high-risk patients. Gastroenterologists often supervise nurses who perform iv sedation for their patients undergoing colonoscopies without the presence of an anesthesiologist. For many patients, this is safe and effective. However, gastroenterologists have guidelines for consulting anesthesiologists when confronted by patients who may have a dififcult airway. Risk factors for a difficult airway include:
1. Severe obesity
2. History of severe sleep apnea
3. Less than 3 cm oral opening in adults
4. Protruding incisors
5. Neck abnormalities (for eg, short thick neck)
Similarly, before administering anesthesia or sedation, I would urge dentists and oral surgeons to consider consulting an anesthesiologist when a patient has risk factors for a difficult airway. Let me be clear - I firmly believe that the vast majority of dentists/oral surgeons can safely handle the anesthesia for the vast majority of patients by themselves with a well-trained office staff. However, there will be a small segment of the patient population who are at higher risk for airway difficulties. For those patients, I believe that an experienced anesthesiologist can be helpful and even life-saving.
Thus, my message to my dental colleagues: When it comes to patients with potentially difficult airways and anesthesia, please know that you can contact me anytime for a complimentary consultation.
Note: I am extremely grateful to the parents of this patient for allowing me to share her story and her photo. The parents of my special needs patients are my heroes. They demonstrate a level of self-sacrifice, compassion and patience that is truly inspiring. It is the highest privilege to be trusted to take care of patients with special needs, and their parents have my deepest respect and admiration.