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Education  |   May 2012
Supraglottic Merkel Cell Carcinoma: A “Cannot Intubate–Cannot Ventilate” Trap
Author Notes
  • Department of Anesthesiology and Perioperative Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
Article Information
Education / Airway Management
Education   |   May 2012
Supraglottic Merkel Cell Carcinoma: A “Cannot Intubate–Cannot Ventilate” Trap
Anesthesiology 5 2012, Vol.116, 1135. doi:10.1097/ALN.0b013e31823ed5da
Anesthesiology 5 2012, Vol.116, 1135. doi:10.1097/ALN.0b013e31823ed5da
A72-YR-OLD woman with neck adenopathy and mild dysphagia presented for laryngoscopy and debulking of a supraglottic Merkel cell carcinoma. She denied hoarseness, dyspnea, and stridor. She had a Mallampati class I airway with normal neck range of motion. There was no evidence by history and physical examination alone to suspect a difficult airway. Computed tomography scan of the neck showed an unexpectedly large 32 mm × 26 mm exophytic mass involving the right aryepiglottic fold (A) and the base of the epiglottis (B). After induction of general anesthesia after an awake fiberoptic intubation, laryngoscopy revealed the massive tumor (C) completely covering the glottic opening and the distal end of the endotracheal tube (D).
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Merkel cell carcinoma is a rare cutaneous neuroendocrine malignancy that seldom presents alarming symptoms.1 The mnemonic AEIOU summarizes its clinical features: A for Asymptomatic, E for Expanding rapidly, I for Immunosuppression, O for Older than 50 yr, and U for Ultraviolet exposure.2 Despite its lack of symptoms, this highly aggressive tumor is potentially dangerous because of its large size and location on the epiglottis.
“Cannot intubate–cannot ventilate” situations are rare but life-threatening events.3 Although the airway may appear deceptively easy, an awake intubation should be performed to prevent this dreaded scenario. With dynamic airway collapse caused by general anesthesia, this tumor carried the risk of falling over the glottis like a trapdoor, leading to complete airway obstruction. An awareness of the risk posed by this rare tumor is essential to prevent airway catastrophes.
References
Wang TS, Byrne PJ, Jacobs LK, Taube JM: Merkel cell carcinoma: Update and review. Semin Cutan Med Surg 2011; 30:48–56
Heath M, Jaimes N, Lemos B, Mostaghimi A, Wang LC, Penas PF, Nghiem P: Clinical characteristics of Merkel cell carcinoma at diagnosis in 195 patients: The AEIOU features. J Am Acad Dermatol 2008; 58:375–81
Wong DT, Lai K, Chung FF, Ho RY: Cannot intubate-cannot ventilate and difficult intubation strategies: Results of a Canadian national survey. Anesth Analg 2005; 100:1439–46
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