Blind Nasotracheal Intubation in a Patient With Ankylosing Spondylitis and Severe Cervical Spine Deformities: A Case Report on Challenges and Approaches to Difficult Airway Management

Abstract

Airway management in patients with advanced ankylosing spondylitis (AS) presents a unique challenge due to possible cervical spine deformities that restrict neck mobility and affect access to the airway. Traditional airway management strategies, such as direct laryngoscopy and even fiberoptic intubation, are often rendered ineffective due to these anatomical limitations. Furthermore, surgical options like tracheostomy can be infeasible in cases with significant neck deformities, necessitating alternative approaches. This case depicts a 48-year-old male with untreated AS who presented to the emergency department following a fall, resulting in unstable vertebral fractures and paraplegia. The patient's severe cervical deformities posed significant challenges to airway management, and conventional airway management strategies, including fiberoptic intubation, were unsuccessful. Given the impracticality of tracheostomy due to the anatomical limitations, blind nasal intubation was successfully performed in a semi-recumbent position. This case underscores the complexities of airway management in AS patients with severe deformities. It highlights the importance of alternative intubation strategies, even blind nasotracheal intubation, when conventional methods fail due to anatomical constraints.

Keywords: ankylosing spondylitis; blind nasotracheal intubation; cervical spine deformities; difficult airway management; intubation challenges.

Figure 1. A 3D reconstruction of a CT scan revealing pronounced cervical deformities, characterized by severe hyperkyphosis and ankylosis (indicated by the white arrow), along with a spinal fracture (denoted by the black arrow).

CT - computerized tomography

Figure 2. Severe cervical spine hyperkyphosis presenting as ''chin-on-chest'' deformity on (A) side and (B) front views.