The Difficult Airway after Endoscopic Endonasal Skull Base Surgery: A Case Series and Management Algorithm

Area of Science:

• Neurosurgery
• Anesthesiology
• Otolaryngology

Background:

• Endoscopic endonasal surgery (EES) for skull base tumors can lead to challenging airway management situations postoperatively.
• Difficult airways pose significant risks, including cerebrospinal fluid leaks and respiratory compromise.

Purpose of the Study:

• To analyze difficult airway events in patients undergoing EES for skull base tumors.
• To develop a structured algorithm for managing these difficult airways.

Main Methods:

• Retrospective review of the Difficult Airway Management Team registry (January 2008–March 2016).
• Analysis of 11 difficult airway events, including patient demographics, event characteristics, and airway management techniques.
• Development of a difficult airway protocol based on collected data.

Main Results:

• Obesity and dural defects repaired with vascularized flaps were common comorbidities.
• Concerns regarding mask ventilation with dural defects and difficult airway anatomy were primary reasons for calls.
• Videolaryngoscopy was the most frequent initial intubation technique; effective adjunctive methods included LMA-assisted ventilation and bougie use.
• LMA-assisted ventilation correlated with reduced cerebrospinal fluid leak; no pneumocephalus, arrest, or mortality occurred.

Conclusions:

• A proposed algorithm offers sequential recommendations for airway management after EES.
• The algorithm emphasizes appropriate techniques and adjunctive measures for difficult airways in this patient population.