How would you approach the airway management in this patient?
Airway assessment begins with careful history-taking and physical examination. A recent history of an unevent-ful intubation may be reassuring; however, anatomic and physiologic changes over the course of 1–5 years may affect one’s ability to manage the airway successfully. Patients without hoarseness or dyspnea and with adequate mouth opening may be approached in the routine manner. Only oral intubation or tracheostomy can be considered for transsphenoidal surgery because a nasal endotracheal tube would obstruct the surgical field. Patients are instructed preoperatively that mouth-breathing will be required in the postoperative period because of bilateral nasal packs. Typical features such as large tongue, large epiglottis, dis-tortion of the larynx, and soft tissue swelling complicate visualization of the larynx in acromegalic patients.
The American Society of Anesthesiologists’ algorithm should be followed in the event of failed intubation and dif-ficult ventilation. If difficulties with the airway are suspected after a careful evaluation, it may be prudent to secure the air-way with the patient awake, either by fiberoptic-guided intu-bation or alternative techniques. Anticipation of the possible need to insert a smaller diameter tracheal tube and minimiz-ing mechanical trauma to the upper airway and vocal cords are important considerations, as additional edema can result in airway obstruction after the tracheal tube is removed.