Management of Difficult Endotracheal Intubation and Challenging Transesophageal Echocardiography Probe Insertion in a Patient With Ankylosing Spondylitis

anesthetic onto a discrete area of the mucosa. A superior laryngeal block was performed bilaterally with 1.5% lidocaine. Finally, 3 mL of 4% lidocaine were injected via the cricothyroid membrane into the trachea to anesthetize the mucosa below the vocal cords. Several efforts were made to intubate the trachea using a fiberoptic bronchoscope. However, secondary to the patient’s immobile cervical spine, limited mouth opening, and unique airway configuration, the laryngeal inlet could not be visualized despite several maneuvers including the tongue being grasped by an assistant and retracted out of the mouth or use of an Ovassapian airway. Additional intravenous sedation (midazolam and fentanyl) and 10 mg of intravenous labetalol were administered during these repeated attempts at airway visualization. Lidocaine and decongestant were then sprayed into the right nasal passage. Fiberoptic visualization of the laryngeal inlet via the nasal route was then attempted; however, this also was unsuccessful. As a final resort, an SGR was then placed in the buccal cavity, rotated forward so that the guide-shield tip of the device approximated the vallecula, and then lifted forward by an assistant. Performing fiberoptic visualization of the laryngeal inlet via the mouth, the position of the SGR was optimized to identify the vocal cords. Once the fiberoptic bronchoscope entered the trachea and rings were identified, an 8.0 endotracheal tube (ET) tube was then advanced over the fiberoptic bronchoscope into the trachea. During the course of the FOI and SGR placement, the patient’s systemic arterial blood pressure and heart rate were maintained within normal limits with intermittent doses of intravenous labetolol (2.5-5 mg); adequate oxygenation was achieved with an open facemask (10 L/min oxygen flow) while the patient breathed spontaneously.