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LETTERS TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 6  |  Page : 503-505  

Hopkins rod endoscope, the saviour for securing airway in tonsillar lymphoma: A case report


1 Department of Anaesthesiology and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Otorhinolaryngology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication11-Jun-2019

Correspondence Address:
Dr. Ankur Gupta
House No. 159, Holi Mohalla, Jind - 126 112, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_72_19

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How to cite this article:
Sarkar S, Luthra A, Gupta A, Chauhan R, Tiwana H. Hopkins rod endoscope, the saviour for securing airway in tonsillar lymphoma: A case report. Indian J Anaesth 2019;63:503-5

How to cite this URL:
Sarkar S, Luthra A, Gupta A, Chauhan R, Tiwana H. Hopkins rod endoscope, the saviour for securing airway in tonsillar lymphoma: A case report. Indian J Anaesth [serial online] 2019 [cited 2019 Aug 22];63:503-5. Available from: http://www.ijaweb.org/text.asp?2019/63/6/503/259947



Sir,

Extra-nodal non-Hodgkin lymphoma (NHL) usually involves the palatine tonsils. The clinical manifestations are enlargement and alteration in the appearance of tonsils, cervical lymphadenopathy, dysphagia, snoring, recurrent upper respiratory tract infection, fever, weight loss and lingual lobe enlargement, which may even lead to stridor.[1],[2] We present a case of tonsillar lymphoma where successful airway management with 0° Hopkins rod averted impending tracheostomy.

A 14-kg, 5-year-old boy presented with low-grade fever and swelling in the oral cavity. The swelling was an enlarged left tonsil (13.6 × 3.4 × 3.7 cm) found to be extending superiorly from hard palate to left vallecula inferiorly, crossing the midline and abutting the left half of epiglottis and the right tonsil [Online Figure 1]. On positron emission tomography - computed tomography (PET-CT), intense fluorodeoxyglucose (FDG) uptake was noted in the enlarged left tonsil [Online Figure 2]. The fine needle aspiration cytology (FNAC) from the tonsillar mass revealed a high-grade NHL. During the course of his stay in the hospital, the child developed stridor and emergency tonsillectomy was planned. On airway examination, Brodsky grade 4 tonsillar swelling and grade 4 modified Mallampati score were noted [Figure 1]. Other airway parameters were non-remarkable with no trismus. The preoperative investigations and vital signs were within normal limits. In the operating room, noninvasive monitoring of blood pressure, electrocardiogram (lead II and V5) and oxygen saturation (SpO2) were applied. A 22-G intravenous (IV) cannula was secured, and IV glycopyrrolate 100 μg and dexamethasone 3 mg were administered. Anaesthesia was induced with IV fentanyl 30 μg and propofol 30 mg. About 2% sevoflurane was started thereafter. After successful bag and mask ventilation, succinylcholine 30 mg was given and video laryngoscopy was performed. The mass on the base of the tongue was found to be pushing the epiglottis posteriorly [Figure 2], and consequently, the first intubation attempt failed. Due to bleeding from the friable tissue during the process, trial by laryngeal mask airway followed by fibre-optic endoscope was ruled out. The child, however, could be successfully ventilated by bag and mask ventilation. It was then decided to use a 0° Hopkins rod endoscope so as to judge the airway anatomy which could help in securing the endotracheal tube into such a compromised airway channel. The distorted anatomy was identified after thorough suctioning and trachea was intubated by using Macintosh 2 blade and 0° Hopkins rod [Online Figure 3]. The otolaryngologist provided the view and anaesthesiologist introduced the endotracheal tube (ETT). Anaesthesia was maintained with atracurium, sevoflurane and nitrous oxide in oxygen. Coblation tonsillectomy was carried out uneventfully. Subsequently ensuring adequate haemostasis, the trachea was extubated after reversing the residual neuromuscular blockade with 1.5 mg neostigmine and 0.3 mg glycopyrrolate.
Figure 1: Airway examination

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Figure 2: (a) Laryngeal inlet in video laryngoscopy and (b) view of laryngeal inlet in 0° Hopkins rod endoscope

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The incidence of extra-nodal NHL involving the Waldeyer's ring (WR) is around 5%. The WR consists of pharyngeal (adenoids), tubal, palatine and lingual tonsils, and about 40–50% WR lymphomas arise from the palatine tonsil.[3]

Tonsillectomy involves a shared airway and airway management in a patient with kissing tonsils is a challenging task for the anaesthesiologist due to increased risk of bleeding during laryngoscopy. The lingual tonsil is fragile as it is devoid of the capsule, in comparison to encapsulated palatine tonsil, which may be a potential source of bleeding.[4],[5]

Hopkins rod telescope is generally used in micro laryngoscopy and bronchoscopy for better optics. A small Hopkins rod bronchoscope may be used to railroad an ETT in difficult airway management, particularly in upper airway pathology as supraglottic cysts or pathology involving the tongue base.[6]

In view of emergency management of a compromised airway, we have used Hopkins rod as an alternative of fibreoptic bronchoscope for rapid manoeuvrability and better optics.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Guimaraes AC, de Carvalho GM, Bento LR, Correa C, Gusmao RJ. Clinical manifestations in children with tonsillar lymphoma: A systematic review. Crit Rev Oncol Hematol 2014;90:146-5.  Back to cited text no. 1
    
2.
Ovassapian A, Glassenberg R, Randel GI, Klock A, Mesnick PS, Klafta JM. The unexpected difficult airway and lingual tonsil hyperplasia: A case series and a review of the literature. Anesthesiology 2002;97:124-32.  Back to cited text no. 2
    
3.
Laskar S, Bahl G, Muckaden MA, Nair R, Gupta S, Bakshi A, et al. Primary diffuse large B-cell lymphoma of the tonsil: Is a higher radiotherapy dose required? Cancer 2007;110:816-23  Back to cited text no. 3
    
4.
Henderson K, Abernathy S, Bays T. Lingual tonsillar hypertrophy: The anesthesiologist's view. Anesth Analg 1994;79:814-5.  Back to cited text no. 4
    
5.
Salvi L, Juliano G, Zucchetti M, Sisillo E. Hypertrophy of the lingual tonsil and difficulty in airway control. A clinical case. Minerva Anestesiol 1999;65:549-53.  Back to cited text no. 5
    
6.
Walker RW, Ellwood J. The management of difficult intubation in children. Pediat Anesth 2009;19:77-87.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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