Successful awake video-laryngoscopic intubation in a patient with a giant mobile vocal process granuloma causing...

Vocal process granulomas are benign laryngeal lesions that are often asymptomatic but can cause critical airway obstruction upon rapid enlargement, although rare. In such cases, conventional induction of general anesthesia may lead to complete airway collapse. Therefore, careful selection of the anesthesia induction technique used is crucial to ensure patient safety, with awake intubation typically being preferred.

A 64-year-old woman presented to the emergency department with progressive dyspnea and stridor over 3 days. She had a history of hoarseness following phacoemulsification under general anesthesia with endotracheal intubation.

Follow-up laryngoscopy revealed a giant, stalked granuloma attached to the posterior one-third of the left vocal cord, nearly obstructing the glottic opening. Preinduction fiberoptic bronchoscopy (FOB) confirmed near-complete dynamic glottic obstruction during inspiration.

Emergency laryngeal microscopic surgery was planned. Due to the high risk of airway compromise during induction, awake video laryngoscope (VL)-guided intubation was selected over FOB-guided intubation, as the latter was limited by its inability to provide simultaneous visualization of the lesion, glottis, and endotracheal tube, as well as by insufficient mechanical support. Airway preparation included topical lidocaine, superior laryngeal nerve block, and transtracheal block. Remifentanil infusion and high-flow nasal oxygen were used to optimize patient comfort and oxygenation. An endotracheal tube with an internal diameter of 5.5 mm was successfully advanced during exhalation using the VL-guided approach.

The surgery was completed without complications. At the 2-week, 2-month, and 1-year follow-ups, the patient remained asymptomatic, and laryngoscopy showed a well-healed surgical site.

Awake VL-guided intubation can be a safe and effective alternative to FOB for managing critical airways caused by giant, mobile vocal process granulomas. This technique offers continuous visualization, facilitates safer tube advancement, and reduces the risk of trauma and highlights the importance of integrating multidisciplinary collaboration and meticulous preinduction planning to optimize airway management.