Ultrasound-guided superior laryngeal nerve block assists in anesthesia for bronchoscopic surgical procedure A case report of anesthesia for rigid bronchoscopy

Introduction: Evolving techniques in the field of therapeutic bronchoscopy have led to the return of rigid bronchoscopy in the treatment of complex central airway disease. Rigid bronchoscopy is typically performed under general anesthesia because of the strong stimulation caused by metal instruments. Anesthesia for rigid bronchoscopy is challenging to administer because anesthesiologists and interventionists share the same working channel: the airway. Previously reviewed anesthetic methods are used primarily for short procedures. Balanced anesthesia with ultrasound-guided superior laryngeal nerve (SLN) block and total intravenous anesthesia might provide anesthesia for a prolonged procedure and facilitate patient recovery. Patient concerns: A patient with obstructed endobronchial stent was referred for therapeutic rigid bronchoscopy, which requires deeper anesthesia than flexible bronchoscopy. There were concerns of the stronger stimulation of the rigid bronchoscopy, lengthy duration of the procedure, higher risk of hypoxemia, and the difficulty of mechanical ventilation weaning after anesthesia due to the patients co-morbidities. Diagnosis: A 66-year-old female patient presented with a history of breast cancer with lung metastases. Right main bronchus obstruction due to external compression of lung metastases was relieved through insertion of an endobronchial stent, but obstructive granulation developed after 4 months. Presence of the malfunctioning stent caused severe cough and discomfort. Removal of the stent by using a flexible bronchoscope was attempted twice but failed. Interventions: Regional anesthesia of the upper airway through ultrasound-guided SLN block combined with intratracheal 2% lidocaine spray was performed to assist in total intravenous anesthesia (TIVA) during rigid bronchoscopy. Outcomes: The patient maintained steady spontaneous breathing throughout the procedure without laryngospasm, bucking, or desaturation. Emergence from anesthesia was smooth and rapid after propofol infusion was discontinued. The surgery lasted 2.5 hours without discontinuity, and no perioperative pulmonary or cardiovascular complications were noted. Conclusion: Ultrasound-guided SLN block is a simple technique with a high success rate and low complication rate. Application of SLN block to assist TIVA provides sufficient anesthesia for lengthened therapeutic rigid bronchoscopy without interruption and facilitates patient recovery.