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Year : 2018  |  Volume : 12  |  Issue : 4  |  Page : 967-969  

Anesthesia management in an adult patient with sleep-disordered breathing and difficult intubation: A case report

Department of Anesthesiology, Padmashree Dr. D. Y. Patil Hospital, Navi Mumbai, Maharashtra, India

Date of Web Publication18-Dec-2018

Correspondence Address:
Dr. Devika Bhatt
Department of Anesthesiology, Padmashree Dr. D. Y. Patil Hospital, 2nd Floor, Sector-5, Nerul, Navi Mumbai - 400 706, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aer.AER_171_18

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Obstructive sleep apnea may be associated with numerous comorbidities and perioperative complications. Poor laryngeal anatomy visualization can be a cause of failed tracheal intubation after multiple attempts in patients with sleep-disordered breathing due to the underlying adenoid enlargement. We present a case of difficult endotracheal intubation in a 52-year-old menopausal female patient posted for tonsillectomy with adenoid resection with a history of snoring and difficulty in breathing while asleep. A thorough preoperative assessment focusing on history and investigating obstructive sleep apnea, and preparing and planning for difficult tracheal intubation in such patients can lead to successful endotracheal intubation inside the operation theater.

Keywords: Anesthesia, difficult intubation, obstructive sleep apnea

How to cite this article:
Bhatt D, Shelke U, Vyas V, Gehdoo R P. Anesthesia management in an adult patient with sleep-disordered breathing and difficult intubation: A case report. Anesth Essays Res 2018;12:967-9

How to cite this URL:
Bhatt D, Shelke U, Vyas V, Gehdoo R P. Anesthesia management in an adult patient with sleep-disordered breathing and difficult intubation: A case report. Anesth Essays Res [serial online] 2018 [cited 2019 Jun 25];12:967-9. Available from:

   Introduction Top

Obstruction of upper airway during anesthesia because of loss of muscle tone may be compounded by obstructive sleep apnea (OSA).[1] OSA can also be associated with perioperative complications such as difficult intubation, re-intubation, and cardiac dysrhythmias.[2] Relation between severity of OSA and difficult intubation is also suggested.[3] Further, anesthesia management in patients with OSA may be challenging because of drug-induced depression of muscle activity.[1] In patients with OSA, anesthetist should be aware and prepared for the management of potential difficulty in airway maintenance. Choice of anesthesia and postoperative management is important in such patients.[1]

Adenoid enlargement may be a cause of OSA. However, adenoid enlargement is not very common among adults.[4] In this article, we are reporting anesthetic management of an adult patient having OSA with adenoid enlargement.

   Case Report Top

A 52-year-old menopausal female weighing 50 kg (body mass index [BMI] = 21.5 kg/m2) posted for tonsillectomy and adenoid resection was referred by the ear, nose, and throat surgery department to the anesthesia preoperative clinic for evaluation. The patient presented with chief complaints of snoring, difficulty in breathing during sleeping, and irritation of the throat for 5 months. In addition, she also complained of dyspnea on exertion with mild-to-moderate activity. The patient was a tobacco chewer for 40 years and had undergone tubal ligation in the past which was uneventful.

Airway examination revealed a mouth opening of three fingers, a Mallampati grade of 3 with bilateral tonsillar enlargement, and a normal thyromental distance. There was no restriction in movement at the joints in the neck/spine. The cervical spine X-ray in the lateral view revealed enlarged adenoids.

Inside the operation theater after attaching the monitors for plethysmograph, capnograph, electrocardiogram, and noninvasive blood pressure, the patient was preoxygenated. The patient was then premedicated with injections glycopyrrolate (0.2 mg), midazolam (1 mg), and fentanyl (2 μg/kg) intravenously, followed by induction with propofol (2 mg/kg) intravenously. After checking for adequate ventilation, the patient was given muscle relaxant intravenous succinylcholine (100 mg). A direct laryngoscopy was performed with Macintosh blade size 4, but the vocal cords were not visualized. The patient was mask ventilated, followed by a direct laryngoscopy with McCoy blade size 4, and tracheal intubation was attempted with the help of a gum-elastic bougie that failed. The patient was mask ventilated again, and AmbuR aView (Ambu A/S, Baltorpbakken) was used through the nasal approach that failed to be negotiated. The patient was mask ventilated again followed by negotiation of AmbuR aView (Ambu A/S, Baltorpbakken) through the mouth where the epiglottis was seen, but the vocal cords were not clearly visualized as a result of the surrounding edema. A cuffed endotracheal tube of size 7.5 mm was threaded over the AmbuR aView (Ambu A/S, Baltorpbakken) and was successfully placed. During the surgery, adenoid resection was performed with tonsillectomy. At 6 weeks' follow-up, the patient reported moderate improvement in the symptoms of snoring and difficulty in breathing during sleeping.

   Discussion Top

Patients with OSA represent at risk of difficult intubation during anesthesia. The causes of OSA and reasons of difficult intubation vary from patient to patient. In our patient, enlarged adenoid was the cause of OSA. Adenoid enlargement among adults can be seen in immunocompromised patients who have received organ transplants or have human immunodeficiency virus.[5] Our patient did not have a history of either of them. Other causes of adenoid enlargement among adults include chronic infection, allergy, sinonasal malignancy, and lymphomas.[5] About 30% of heavy smokers present with obstructive adenoids.[5],[6] Our patient was female with no history of smoking.

There is a close relation between OSA and difficult endotracheal intubation.[7] The incidence of difficult tracheal intubation is higher among patients with OSA patients as compared to those not having OSA.[8] Some evidence suggests that OSA is not associated with difficult intubation.[9] The STOP-Bang questionnaire score is useful for evaluation of risk of difficult airway in obese patients with unknown OSA status.[10]

A study has suggested no significant correlation between weight or BMI with difficult intubation in patients with OSA.[11] Our observation is in accordance to these findings. Factors associated with difficult intubation include higher apnea–hypopnea index and neck circumference.[11]

Literature review also suggests difficulty in mask ventilation among patients with OSA. The incidence of difficult mask ventilation has been reported to be higher among OSA patients than non-OSA patients.[8] In our patient, mask ventilation was not difficult. A study utilizing a questionnaire to predict difficult airway among patients diagnosed with OSA undergoing ENT surgery reported that 18.7% of patients with OSA syndrome have difficult airways of Cormack III/IV.[12] Measures such as “proper body and head position, sufficient preoxygenation, effective airway maneuvers, and continuous assessment of ventilation may help to reduce respiratory complications during anesthesia induction”.[13] In our case, monitoring was performed with plethysmograph, capnograph, and electrocardiogram. Sufficient preoxygenation was ensured.

Premedication with glycopyrrolate, midazolam, and fentanyl, followed by induction with propofol and muscle relaxation with intravenous succinylcholine, was useful in our case. Mask ventilation, direct laryngoscopy, and negotiation of AmbuR aView (Ambu A/S, Baltorpbakken) through the mouth were used for airway management. Adenoid resection with tonsillectomy resulted in improvement in the symptoms of the patient.

   Conclusion Top

Sleep-disordered breathing (OSA) should be thoroughly evaluated. Structural abnormalities of the airways such as tonsillar and adenoid enlargement accompanied with OSA should guide the anesthesiologist for planning measures for anticipated difficult intubation.

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.


The authors wish to thank Dr. Anant D Patil for his contribution in editing the manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Hillman DR, Loadsman JA, Platt PR, Eastwood PR. Obstructive sleep apnoea and anaesthesia. Sleep Med Rev 2004;8:459-71.  Back to cited text no. 1
Park JG, Ramar K, Olson EJ. Updates on definition, consequences, and management of obstructive sleep apnea. Mayo Clin Proc 2011;86:549-54.  Back to cited text no. 2
Kim JA, Lee JJ. Preoperative predictors of difficult intubation in patients with obstructive sleep apnea syndrome. Can J Anaesth 2006;53:393-7.  Back to cited text no. 3
Yildirim N, Sahan M, Karslioğlu Y. Adenoid hypertrophy in adults: Clinical and morphological characteristics. J Int Med Res 2008;36:157-62.  Back to cited text no. 4
Rout MR, Mohanty D, Vijaylaxmi Y, Bobba K, Metta C. Adenoid hypertrophy in adults: A case series. Indian J Otolaryngol Head Neck Surg 2013;65:269-74.  Back to cited text no. 5
Finkelstein Y, Malik Z, Kopolovic J, Bernheim J, Djaldetti M, Ophir D, et al. Characterization of smoking-induced nasopharyngeal lymphoid hyperplasia. Laryngoscope 1997;107:1635-42.  Back to cited text no. 6
Acar HV, Yarkan Uysal H, Kaya A, Ceyhan A, Dikmen B. Does the STOP-bang, an obstructive sleep apnea screening tool, predict difficult intubation? Eur Rev Med Pharmacol Sci 2014;18:1869-74.  Back to cited text no. 7
Leong SM, Tiwari A, Chung F, Wong DT. Obstructive sleep apnea as a risk factor associated with difficult airway management – A narrative review. J Clin Anesth 2018;45:63-8.  Back to cited text no. 8
Vest D, Lee D, Newcome K, Stamper H. A retrospective review of difficult intubations: Is obstructive sleep apnea a predictor? Clin Nurse Spec 2013;27:128-31.  Back to cited text no. 9
Toshniwal G, McKelvey GM, Wang H. STOP-bang and prediction of difficult airway in obese patients. J Clin Anesth 2014;26:360-7.  Back to cited text no. 10
Lee SJ, Lee JN, Kim TS, Park YC. The relationship between the predictors of obstructive sleep apnea and difficult intubation. Korean J Anesthesiol 2011;60:173-8.  Back to cited text no. 11
Pera MH, Tardelli MA, Novo NF, Juliano Y, Silva HC. Correlation between obstructive apnea syndrome and difficult airway in ENT surgery. Rev Bras Anestesiol 2018;68:543-8.  Back to cited text no. 12
Sato Y, Ikeda A, Ishikawa T, Isono S. How can we improve mask ventilation in patients with obstructive sleep apnea during anesthesia induction? J Anesth 2013;27:152-6.  Back to cited text no. 13


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