A 65-year-old woman was scheduled for
total knee replacement. She had been suffering from
rheumatoid arthritis for 22 years. She also had a history of occasional acute
dyspnea, which had been diagnosed as asthmatic
bronchitis. Preoperative examinations of the airway revealed limited neck flexion, a small jaw, and normal mouth opening. After epidural catheterization,
anesthesia was induced with
propofol, and a #3 laryngeal mask airway (LMA) was inserted. However, her lungs could not be ventilated through the LMA. Despite repeated attempts, proper placement of the LMA could not be achieved. Hence, a 7.0 mm ID armored endotracheal tube was inserted through an intubating LMA.
Anesthesia was maintained with
nitrous oxide and
sevoflurane in
oxygen. The surgery proceeded uneventfully. Five minutes after extubation, inspiratory
dyspnea occurred. The patient's trachea was re-intubated nasally with a bronchofiberscope. Since the bronchofiberscopy revealed remarkable
laryngeal edema, percutaneous
tracheostomy was performed. On the 3 rd postoperative day, cricoarytenoid
arthritis that had caused occasional
airway obstruction was diagnosed, although her
laryngeal edema disappeared. She went home with a permanent
tracheostomy. Although cricoarytenoid
arthritis is a common occurrence in patients with
rheumatoid arthritis, the diagnosis can be difficult. A scrupulous preoperative evaluation and awareness of cricoarytenoid
arthritis are necessary for optimal
anesthetic management.