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Case Reports
. 2019 Jul 9;19(1):124.
doi: 10.1186/s12871-019-0798-3.

Ultrasonographic identification of the cricothyroid membrane in a patient with a difficult airway as a result of cervical hematoma caused by hemophilia: a case report

Ippei Jimbo  1 , Kohji Uzawa  2 , Joho Tokumine  1 , Shingo Mitsuda  1 , Kunitaro Watanabe  1 , Tomoko Yorozu  1
Affiliations
Case Reports

Ultrasonographic identification of the cricothyroid membrane in a patient with a difficult airway as a result of cervical hematoma caused by hemophilia: a case report

Ippei Jimbo et al. BMC Anesthesiol. .

Abstract

Background: Surgical cricothyroidotomy is a last resort in patients with an anticipated difficult airway, but without any guarantee of success. Identification of the cricothyroid membrane may be the key to successful cricothyrotomy. Ultrasonographic identification of the cricothyroid membrane has been reported to be more useful than the conventional palpation technique. However, ultrasonographic identification techniques are not yet fully characterized.

Case presentation: A 28-year-old man with hemophilia and poor adherence to medication. He was brought to the emergency department with a large cervical hematoma and respiratory difficulty. An otolaryngologist decided to insert a tracheal tube to maintain his airway. However, emergent laryngoscopy indicated an anticipated difficult airway. A backup plan that included awake intubation by the anesthesiologists and surgical cricothyroidotomy by an otolaryngologist was devised. The cricothyroid membrane could not be identified by palpation but was detected by ultrasonographic identification with a longitudinal approach. Awake fiberoptic intubation was successfully performed.

Conclusions: In this case, the cricothyroid membrane could be identified using the longitudinal approach but not the transverse approach. It may be ideal to know which ultrasound technique can be applied for each patient.

Keywords: Cricothyroid membrane; Cricothyroidotomy; Difficult airway; Hemophilia; Ultrasonography.

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Conflict of interest statement

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

Figures

Fig. 1
Fig. 1
Clinical photograph showing the neck swelling caused by the large hematoma
Fig. 2
Fig. 2
Transnasal endoscopic findings in the laryngeal cavity. The image shows a swollen epiglottis with a mass on the right side of the epiglottis. The vocal cords can be seen under the swollen epiglottis
Fig. 3
Fig. 3
Cervical ultrasonographic images obtained using the longitudinal approach. Either the transverse or longitudinal approach can be used for ultrasonographic identification of the cricothyroid membrane (CTM). Using the transverse approach, the operator manipulates the ultrasound probe while tilting it up and down on the patient’s neck to locate the CTM; if the operator is attempting to locate a deeply positioned CTM (a), the angle of tilt of the probe may be restricted, and is shown as a window (a, red lettering). In contrast, if the CTM is in a shallow position (b), the angle of tilt of the probe may be wider using the transverse approach. However, there is no need to tilt the probe when using the longitudinal approach. a An ultrasonographic image of the patient’s neck using the longitudinal approach. b An ultrasonographic image of the first author’s neck using the longitudinal approach. The first author is a healthy male adult with a standard physique (height 174 cm, body weight 68 kg). T, thyroid cartilage; C, cricoid cartilage; CTM, cricothyroid membrane
See this image and copyright information in PMC

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