Emergency Cricothyroidotomy for Acute Epiglottitis in a Patient With Super-Super Obesity: A Case Report.

Acute epiglottitis is uncommon in adults but can obstruct the airway within hours. Although few patients require airway intervention, those who do present one of the highest-risk intubation scenarios in clinical practice. Obesity further complicates physiological or technical challenges of airway management. It shortens safe apnea time, weakens the seal of a facemask or supraglottic device, hides the neck landmarks needed for a surgical airway, and can make imaging of the neck uninterpretable. A 39-year-old man presented with two days of sore throat, dysphagia, and a muffled voice. He had asthma, hypertension, and severe obstructive sleep apnea treated with home continuous positive airway pressure. His body mass index was 66.5 kg/m2, with a weight of more than 200 kg. Urgent care had treated him for pharyngitis after a negative rapid streptococcal test. In the emergency department, the working diagnosis was angioedema. Intravenous dexamethasone and intramuscular epinephrine initially improved his symptoms over three hours, and then he deteriorated again. A lateral neck radiograph was reported as markedly limited by body habitus, and he declined a computed tomography scan because he could not tolerate supine positioning. After induction with intravenous ketamine, intubation with video laryngoscopy failed because the epiglottis was too swollen to admit an endotracheal tube, and oxygen saturation fell to 62%. Fiberoptic laryngoscopy was also unable to pass the swollen epiglottis, with a second desaturation to 69%. Laryngeal mask airway placement, only with an extensive two-handed jaw thrust maneuver, restored saturation to 99%, and a general surgeon performed a bedside cricothyroidotomy, placing a 6.0 mm endotracheal tube 40 minutes after the decision to intubate. Tracheostomy was attempted in the operating room but aborted because the trachea lay too deep. On hospital day 4, an otolaryngologist drained an epiglottic abscess and exchanged the cricothyroidotomy tube for an oral endotracheal tube through direct laryngoscopy with rigid and fiberoptic bronchoscopies, and cultures grew group G beta-hemolytic Streptococcus. Severe acute respiratory distress syndrome, biventricular systolic dysfunction, bilateral deep vein thromboses despite prophylaxis, and a peroneal compressive neuropathy followed. He went home on hospital day 46 with the cricothyroidotomy stoma still open. Three lessons follow. First, an improved response to steroids and epinephrine in supraglottic obstruction can still be temporary and should not be read as a trend. Second, in a patient of this size, one failed intubation attempt can be all that separates a stable airway from a "cannot intubate, cannot oxygenate" emergency. And, third, a cricothyroidotomy tube in a deep neck is not a definitive airway and may not hold its position, so the plan for converting it should be established before placement.