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).
Merkel cell carcinoma is a rare cutaneous neuroendocrine malignancy that seldom presents alarming symptoms.1The 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.2Despite 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.3Although 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.
