Department of Emergency Medicine, Faculty of Medicine, MARA University of Technology, Selangor, Malaysia *Corresponding Author’s e-mail: alif_1979@yahoo.com نقطة الرعاية للمسلك اهلوائي بتخطيط الصدى قبل عملية بضع الغشاء احللقي الدرقي الطارئة تقرير حالة حممد اإقبال، جولينا حممد نور، نور عبدالكرمي، اإيزات اإ�شماعيل، حليم �شنيب، حممد اأمني خمتار، �شفريدا �شامل abstract: The use of ultrasonography in acute and critical care medicine is becoming increasingly common. However, use of an airway ultrasound as an adjunct to determine the type of intervention needed and assess complications is not common practice. We report a 56-year-old male who presented to the Emergency Department of the Sungai Buloh Hospital, Selangor, Malaysia, in 2015 with hoarseness, stridor and impending respiratory failure. A point-of-care ultrasound performed to assess the neck and vocal cords indicated a heterogeneous echogenic mass in the larynx, thus ruling out a cricothyroidotomy. The patient was therefore referred for an emergency tracheostomy. This case highlights the importance of point-of-care airway ultrasonography in the assessment of patients with stridor. This imaging technique not only helps to detect the cause of the stridor, but also to determine the feasibility of a cricothyroidotomy in emergency cases. Keywords: Emergency Medicine; Stridor; Ultrasonography; Airway Management; Tracheostomy; Case Report; Malaysia. فوق املوجات ا�شتخدام اأن، ومع متزايد. ب�شكل �شائعًا اأمراً واحلرجة احلادة الرعاية طب يف ال�شدى تخطيط ا�شتخدام اأ�شبح امللخ�ص: حالة نعر�ض ال�شتخدام. �شائعة غري اأنها اإل امل�شاعفات وتقييم املطلوب التدخل نوع لتحديد م�شاعدة تعترب الهوائي للم�شلك ال�شوتية مري�ض ذكر عمره 56 عامًا تقدم لق�شم الطوارئ مب�شت�شفى �شونغاي بوله، �شيلنجور، ماليزيا، يف 2015 باأعرا�ض بحة، �رضير و ف�شل تنف�شي و�شيك. مت تقدمي نقطة الرعاية با�شتخدام املوجات فوق ال�شوتية لتقييم الرقبة واحلبال ال�شوتية والتي اأظهرت وجود كتلة متغايرة مولدة لل�شدى يف البلعوم، وبالتايل مت اأ�شتبعاد اإجراء ب�شع الغ�شاء احللقي الدرقي. مت بذلك حتويل املري�ض لإجراء فغر الرغامى الطارئ. هذه احلالة ت�شلط ال�شوء على اأهمية تخطيط ال�شدى يف نقطة الرعاية للم�شلك الهوائي عند تقييم املر�شى الذين يعانون من �رضير. هذه التقنية الت�شويرية ل ت�شاعد فقط على اكت�شاف �شبب ال�رضير، ولكن اأي�شا حتدد جدوى عملية ب�شع الغ�شاء احللقي الدرقي يف احلالت الطارئة. الكلمات املفتاحية: طب الطوارئ؛ �رضير؛ تخطيط ال�شدى؛ عالج امل�شلك الهوائي؛ فغر الرغامى؛ تقرير حالة؛ ماليزيا. Point-of-Care Airway Ultrasonography Prior to an Emergency Cricothyroidotomy Case report *Mohamad Iqhbal, Julina M. Noor, Nur A. Karim, Izzat Ismail, Halim Sanib, Mohd A. Mokhtar, Safreeda S. F. Salim casE rEport Sultan Qaboos University Med J, May 2018, Vol. 18, Iss. 2, pp. e219–222, Epub. 9 Sep 18 Submitted 6 Nov 17 Revision Req. 12 Dec 17; Revision Recd. 8 Jan 18 Accepted 1 Feb 18 doi: 10.18295/squmj.2018.18.02.017 The presence of stridor indicates anupper airway obstruction.1 In emergency depart- ments, patients with stridor are often treated emergently according to strict management proto- cols. In such cases, the attending physician must be able to evaluate the patient and determine the type of airway management intervention required, such as a cricothyroidotomy.1 However, with the high rate of success of newer airway management techniques, such as orotracheal intubation, rates of cricothyroidotomies have declined over the past decade to approximately 0.4–1.2%.2–5 Unfortunately, as this procedure is uncommon, the prevalence of complications during a cricothyroid- otomy can vary from 6.1–54.5%, depending on the clinical circumstances of the case, technique employed and experience of the surgeon.6,7 Although point- of-care ultrasonography (POCUS) is very useful in critical care and acute medicine, its role in airway management is not routine, even though several studies have advocated its use.8–10 The current case demon- strates the benefits of POCUS in assessing the airway of a patient with stridor and informing the choice of emergency airway intervention. Case Report A 56-year-old male presented to the Emergency Department of the Sungai Buloh Hospital, Selangor, Malaysia, in 2015 with shortness of breath, stridor and hoarseness. He had started experiencing breathing difficulties and coryzal symptoms a few months prev- iously. The patient reported that the hoarseness had begun about six months prior to presentation and Point-of-Care Airway Ultrasonography Prior to an Emergency Cricothyroidotomy Case report e220 | SQU Medical Journal, May 2018, Volume 18, Issue 2 was associated with weight loss, loss of appetite and dysphagia. However, he was still able to eat and drink. He had seen a local general practitioner but these symptoms had not been investigated. One week prior to presentation, he started to experience noisy breathing precipitated by an upper respiratory tract infection and he reported feeling breathless upon exertion. At presentation, the patient could sit upright and was mildly tachypnoeic with inspiratory stridor. His breathing sounds were normal and he was able to talk in a hoarse voice without drooling. His blood pressure was 118/80 mm Hg and he had a pulse rate of 70 beats per minute. Oxygen saturation was at 98% with a nasal cannula. A clinical examination revealed no visible mass in the head, neck or chest region and the trachea appeared to be centrally located. There were also no signs of venous distension of the neck or chest wall or evidence of facial or upper extremity oedema. An airway ultrasound was performed to investigate the structure of the airway and identify the cause of the stridor. Notably, this revealed a hyperechoic artefact extending throughout the cricoid cartilage, which was inconsistent with the structure of a normal airway [Figure 1]. The mass had ill-defined borders with heterogeneous echogenicity [Figure 2]. Anticipating that airway management would be difficult and potentially involve intubation or a cricothyroidotomy, the patient was referred to the otorhinolaryngology team for further assessment and definitive management. Flexible laryngoscopy revealed a fungating mass involving the false vocal cords and extending to the subglottic region [Figure 3]. As the patient was stable and able to maintain oxygenation, he underwent an emergency tracheostomy. Later, a computed tomography scan was suggestive of a laryngeal carcinoma [Figure 4], which was successfully removed. Figure 3: Flexible laryngoscopic image of the airway of a 56-year-old male showing an intraluminal fungating mass (arrow). Figure 1: Longitudinal point-of-care airway ultrasonography of (A) a 56-year-old male with stridor showing a distorted cricothyroid membrane with a mass underneath (arrow) in comparison to (B) an example of a normal airway. TC = thyroid cartilage; CTM = cricothyroid membrane; CC = cricoid cartilage. Figure 2: Transverse point-of-care airway ultrasonography of (A) the airway of a 56-year-old male with stridor showing intraluminal heterogeneous echogenic mass (arrow) in comparison to (B) an example of a normal airway. SM = sternohyoid muscle; CTM = cricothyroid membrane; T = trachea. Mohamad Iqhbal, Julina M. Noor, Nur A. Karim, Izzat Ismail, Halim Sanib, Mohd A. Mokhtar and Safreeda S. F. Salim Case Report | e221 thyroidotomy skills in emergency medicine and critical care training, particularly in view of the reliability of this technique and its association with fewer complications compared to conventional methods.16 Conclusion Routine POCUS should be considered in certain high- risk situations requiring emergency airway manage- ment, such as stridor and neck haematomas and masses. In such cases, the identification of an abnormal anat- omical structure in the airway would make a conven- tional cricothyroidotomy unfeasible; hence, an alter- native approach is required, such as a tracheostomy. References 1. Nemeth J, Maghraby N, Kazim S. Emergency airway manage- ment: The difficult airway. Emerg Med Clin North Am 2012; 30:401−20. doi: 10.1016/j.emc.2011.12.005. 2. Bushra JS, McNeil B, Wald DA, Schwell A, Karras DJ. A comparison of trauma intubations managed by anesthesiologists and emergency physicians. Acad Emerg Med 2004; 11:66−70. doi: 10.1197/j.aem.2003.08.013. 3. Tayal VS, Riggs RW, Marx JA, Tomaszewski CA, Schneider RE. Rapid-sequence intubation at an emergency medicine residency: Success rate and adverse events during a two-year period. Acad Emerg Med 1999; 6:31−7. doi: 10.1111/j.1553-2712.1999. tb00091.x. 4. Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: A one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325−32. doi: 10.1016/S0196-0644(98)70342-7. 5. Levitan RM, Rosenblatt B, Meiner EM, Reilly PM, Hollander JE. Alternating day emergency medicine and anesthesia resident responsibility for management of the trauma airway: A study of laryngoscopy performance and intubation success. Ann Emerg Med 2004; 43:48−53. doi: 10.1016/S0196-0644(03)00638-3. 6. Bair AE, Panacek EA, Wisner DH, Bales R, Sakles JC. Crico- thyrotomy: A 5-year experience at one institution. J Emerg Med 2003; 24:151−6. doi: 10.1016/S0736-4679(02)00715-1. 7. Brantigan CO, Grow JB Sr. Cricothyroidotomy: Elective use in respiratory problems requiring tracheotomy. J Thorac Cardio- vasc Surg 1976; 71:72−81. Discussion In acute care medicine, delays in airway management can result in poor outcomes.11 Emergency airway inter- ventions range from laryngoscopy to a cricothyroid- otomy, with the latter being a last life-saving resort when all other measures fail. Traditionally, a crico- thyroidotomy is performed blindly as a form of emergent airway management.12 Prior to the procedure, the cricothyroid membrane is identified based on surface landmarks and palpation. However, Elliott et al. demonstrated that this membrane was only correctly identified by 30% of anaesthetists, of which only 11% could locate the midline.13 In such cases, the cricothyroidotomy tube can be misplaced due to the inaccurate identification of these anatomical landmarks. In addition, technical problems in 40% of cases have been noted during cricothyroidotomies performed using the Seldinger technique.14 In comparison, POCUS is a noninvasive and readily available technique. Furthermore, it can provide detailed information regarding the anatomy of the airway as all of the internal structures can be visualised in a short period of time by placing the linear probe at the centre of the neck.15 Prior to an emergency cricothyroidotomy, an ultrasound allows for the reliable and rapid identification of the crico- thyroid membrane and trachea, unaffected by the patient’s body mass index.16,17 The current case highlights the importance of POCUS, not only in the accurate localisation of anat- omical landmarks, but also in the identification of any internal structural abnormalities and, consequently, the feasibility of performing a cricothyroidotomy. While it may be argued that POCUS is not expedient in a time-sensitive situation, failure and complication rates remain high for emergency cricothyroidotomies performed blindly, thus delaying critical life-saving interventions in any case.18 As such, the authors advocate the incorporation of POCUS-guided crico- Figure 4: Computed tomography scans of the airway of a 56-year-old male in the (A) sagittal view showing an irregular mass obstruction (arrow) extending to the lower border of the cricoid cartilage and (B) axial view showing the severely stenosed airway. 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Ultra- sonography for clinical decision-making and intervention in airway management: From the mouth to the lungs and pleurae. Insights Imaging 2014; 5:253−79. doi: 10.1007/s13244-014-0309-5. 11. Bauer PR, Gajic O, Nanchal R, Kashyap R, Martin-Loeches I, Sakr Y, et al. Association between timing of intubation and outcome in critically ill patients: A secondary analysis of the ICON audit. J Crit Care 2017; 42:1–5. doi: 10.1016/j.jcrc.2017.06.010. 12. Shannon NJ, Shannon GD. “Blind” emergency cricothyrotomy in patients with complicating factors under adverse cond- itions. Wilderness Environ Med 1998; 9:260–1. doi: 10.1580/ 1080-6032(1998)009[0260:LTTE]2.3.CO;2. 13. Elliott DS, Baker PA, Scott MR, Birch CW, Thompson JM. Accuracy of surface landmark identification for cannula cricothyroidotomy. 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