Special features of anesthesia: the difficult airway

  • Chapter: Pain therapy and anesthesia

    Article: 7 of 8

    Update: Feb 24, 2021

  • Author(s): Kramer, Jens

In some cases, general anesthesia is necessary for a variety of reasons, even if the patient has special pre-existing comorbidities and anatomical preconditions. From the anesthesiology point of view, the difficult airway deserves a special mention in this respect. If the vascular malformation involves the upper airways, there are two specific aspects:

  • Securing of the airway during the procedure
  • The risk of swelling post-intervention

Very close coordination between the attending radiologist and the responsible anesthesiologist in advance is mandatory. The following aspects must be considered:

  • Are there current findings (imaging, endoscopy) regarding the airway or experience from previous anesthesia (ENT consultation, previous anesthesia protocols, anesthesia passport)?
  • Are alternative procedures available to secure the airway (e.g., video laryngoscopy, fiber-optic procedures, laryngeal masks)?
  • Might a secondary airway problem arise after the intervention due to anticipated swelling, e.g., because of sclerosing or embolizing agents (make intensive care bed available for postoperative ventilation)?

If a difficult airway is suspected, the most important point is early joint interdisciplinary coordination and discussion before the procedure. This is especially important in the event that difficulties actually arise. The necessary equipment must be available on site at the time of the planned procedure, as must the necessary expertise.

Clinical example

The interdisciplinary procedure in the case of a foreseeably difficult airway is illustrated by the following example:

  • Male patient aged 24 years.
  • There is a voluminous venous malformation in the neck.
  • The malformation extends into the piriform sinus and the glottic plane (hypopharynx).
  • There was a history of previous upper airway bleeding.

Planned intervention:

  • Local sclerotherapy of the venous malformation by direct puncture under laryngoscopic control.

Planned procedure:
During an interdisciplinary consultation between radiology, anesthesiology, and ENT, the following consensus was reached:

  • The top priority is to avoid severe bleeding due to uncontrolled manipulations, for example, during direct laryngoscopy.
  • Awake fiber-optic intubation was not considered necessary.


  • Conventional induction of anesthesia with mask ventilation without problems.
  • Direct laryngoscopy or intubation by an experienced senior anesthesiology physician was not possible.
  • This was followed by microlaryngoscopy by a senior ENT physician.
  • After several careful attempts, a 5.0 tube was successfully placed without manifest bleeding.
  • After successful intervention, a repeat microlaryngoscopy was performed and the decision was made to proceed with primary extubation.
  • No respiratory problems occurred post-intervention.