Difficult airway due to cervical haemorrhage caused by spontaneous rupture of a parathyroid adenoma: A case report.

BACKGROUND: Cervical haemorrhage due to spontaneous rupture of a parathyroid adenoma is a rare complication that may cause life-threatening acute airway compromise. CASE SUMMARY: A 64-year-old woman was admitted to the hospital 1 day after the onset of right neck enlargement, local tenderness, head-turning difficulty, pharyngeal pain, and mild dyspnoea. Repeat routine blood testing showed a rapid decrease in the haemoglobin concentration, indicating active bleeding. Enhanced computed tomography images showed neck haemorrhage and a ruptured right parathyroid adenoma. The plan was to perform emergency neck exploration, haemorrhage removal, and right inferior parathyroidectomy under general anaesthesia. The patient was administered 50 mg of intravenous propofol, and the glottis was successfully visualised on video laryngoscopy. However, after the administration of a muscle relaxant, the glottis was no longer visible and the patient had a difficult airway that prevented mask ventilation and endotracheal intubation. Fortunately, an experienced anaesthesiologist successfully intubated the patient under video laryngoscopy after an emergency laryngeal mask placement. Postoperative pathology showed a parathyroid adenoma with marked bleeding and cystic changes. The patient recovered well without complications. CONCLUSION: Airway management is very important in patients with cervical haemorrhage. After the administration of muscle relaxants, the loss of oropharyngeal support can cause acute airway obstruction. Therefore, muscle relaxants should be administered with caution. Anaesthesiologists should pay careful attention to airway management and have alternative airway devices and tracheotomy equipment available.

Effect of single spinal anesthesia with two doses ropivacaine on urinary retention after hemorrhoidectomy in male patients.

Background: Anorectal diseases are common in the population and include internal, external, and mixed hemorrhoids. Although hemorrhoid surgery is a brief operation, anesthesia, anesthetic drugs, drug concentrations, and anesthesia level control are closely related to postoperative uroschesis. For hemorrhoid surgery, a single spinal block with ropivacaine is commonly used that blocks the S2-S4 parasympathetic nervous system, which in turn governs the voiding reflex, causing postoperative urinary retention; this affects the recovery of patients. This study was performed to investigate the effects of two doses ropivacaine that provided satisfactory analgesia and muscle relaxation and inhibited adverse reflexes on urinary retention after hemorrhoidectomy. Methods: The study included 200 male patients who underwent anorectal surgery with American Society of Anesthesiologists (ASA) grade I-II single elective spinal anesthesia between March 2021 and March 2022. Patients were randomly assigned to 2 groups using a random number table: Group A (n = 100) received 10 mg 0.5% ropivacaine (1.5 ml 1% ropivacaine + 1.5 ml 10% glucose = 3 ml), and Group B (n = 100) received 15 mg 0.5% ropivacaine (1.5 ml 1% ropivacaine + 1.5 ml 10% glucose = 3 ml). Results: The anal sphincter exhibited good relaxation, and no obvious traction pain or significant difference in the time of muscle strength recovery was observed between the 10 mg and 15 mg 0.5% ropivacaine groups (P > 0.05). The 10 mg 0.5% ropivacaine group had shorter time of micturition exceeding 100 ml and lower voiding International Prostate Symptom Score than the 15 mg 0.5% ropivacaine group (P < 0.01). Conclusions: Single spinal anesthesia with 10 mg 0.5% ropivacaine not only provides satisfactory anesthetic effect for hemorrhoidectomy but also has less influence on postoperative uroschesis and is worthy of clinical application. Trial registration: The study was registered in the Chinese Clinical Trial Registry (http://www.chictr.org.cn; identifier: ChiCTR2,100,043,686) on February 27, 2021.

Radiological indicators to predict the application of assistant intubation techniques for patients undergoing cervical surgery.

BACKGROUND: We aimed to distinguish the preoperative radiological indicators to predict the application of assistant techniques during intubation for patients undergoing selective cervical surgery. METHODS: A total of 104 patients were enrolled in this study. According to whether intubation was successfully accomplished by simple Macintosh laryngoscopy, patients were divided into Macintosh laryngoscopy group (n = 78) and Assistant technique group (n = 26). We measured patients' radiographical data via their preoperative X-ray and MRI images, and compared the differences between two groups. Binary logistic regression model was applied to distinguish the meaningful predictors. Receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to describe the discrimination ability of indicators. The highest Youden's index corresponded to an optimal cut-off value. RESULTS: Ten variables exhibited significant statistical differences between two groups (P <  0.05). Based on logistic regression model, four further showed correlation with the application of assistant techniques, namely, perpendicular distance from hard palate to tip of upper incisor (X2), atlanto-occipital gap (X9), angle between a line passing through posterior-superior point of hard palate and the lowest point of the occipital bone and a line passing through the anterior-inferior point and the posterior-inferior point of the second cervical vertebral body (Angle E), and distance from skin to hyoid bone (MRI 7). Angle E owned the largest AUC (0.929), and its optimal cut-off value was 19.9° (sensitivity = 88.5%, specificity = 91.0%). the optimal cut-off value, sensitivity and specificity of other three variables were X2 (30.1 mm, 76.9, 76.9%), MRI7 (16.3 mm, 69.2, 87.2%), and X9 (7.3 mm, 73.1, 56.4%). CONCLUSIONS: Four radiological variables possessed potential ability to predict the application of assistant intubation techniques. Anaesthesiologists are recommended to apply assistant techniques more positively once encountering the mentioned cut-off values.

Neck circumference to inter-incisor gap ratio: a new predictor of difficult laryngoscopy in cervical spondylosis patients.

BACKGROUND: Preoperative airway assessment help anticipate a difficult airway. We hypothesized that a close association existed between difficult laryngoscopy and the neck circumference/inter-incisor gap ratio (RNIIG). Our aim was to determine its utility in predicting difficult laryngoscopy in cervical spondylosis patients. METHODS: Two hundred thirteen consecutive patients, aged 20-70 years, scheduled to undergo cervical spine surgery under general anesthesia, were recruited. Preoperative assessments included inter-incisor gap (IIG), thyromental distance (TMD), neck circumference (NC), NC/IIG ratio (RNIIG), NC/TMD ratio (RNTMD) and modified Mallampati test (MMT). Cormack-Lehane scales were assessed during intubation. The anesthesiologist was blinded to the airway assessments. RNIIG's ability to predict difficult laryngoscopy was compared with that of established predictors. RESULTS: Difficult laryngoscopy incidence was 16.4%. Univariate analysis showed that male gender, increased age, weight, NC, RNIIG and RNTMD, decreased IIG and TMD, and MMT 3 and 4 were associated with difficult laryngoscopy. Binary multivariate logistic regression analyses identified only one factor that was independently associated with difficult laryngoscopy: RNIIG. The odds ratio and 95% confidence interval (95% CI) were 1.932 (1.504-2.482). RNIIG (≥9.5) exhibited the largest area under the curve (0.80; 95% CI 0.73-0.86) and the highest sensitivity (88.6%; 95% CI 78.1-99.1) and negative predictive value (96.6%; 95% CI 94.0-99.2), confirming its better predictive ability. CONCLUSIONS: RNIIG is a new and simple predictor with a higher level of efficacy, and could help anesthetists plan for difficult laryngoscopy management in cervical spondylosis patients. TRIAL REGISTRATION: ChiCTR-OON-16008320 (April 19th, 2016).