-
Practice your interview with the new SDN AI Interview Coach. Choose a school, answer by voice or typing, and receive a personalized feedback report. Available now to all SDN members. Try the AI Interview Coach.
They left out the “awake” fiber optic portion of the answer. I think that’s where a lot of people got messed up. And two anesthesia providers available for elective awake fiber optic intubation because it can literally require two people who know what they are doing.
Yes the safe thing to do is to postpone the procedure. This is where pat clinic or some type of properties evaluation is helpful.
Yes the safe thing to do is to postpone the procedure. This is where pat clinic or some type of properties evaluation is helpful.
Advertisement - Members don't see this ad
Elective? Cancel and Consult ENT... is he safe for trache if emergency airway needed? Probably. What size tube can i get in there? Because the scan doesn't show a ruler measurement of the cross section airway. what does his voice sound like? what does previous scan show?
I could probably get the scope in but not pass the tube, even a MLT tube would not pass atraumaticly through that goose neck.
I could probably get the scope in but not pass the tube, even a MLT tube would not pass atraumaticly through that goose neck.
@dmk5n Assuming elective. Agreed with everything you said. The whole thing was just glib, and it’s like, what kind of case, what’s the urgency, why I am finding out about this at the bedside, am I going to be able to extubate this guy safely? Such a terrible scenario and “correct” answer, I’m astounded that Doximity let that get through.
Google Gemini answer is good ! Maybe we are replaceable
“
Based on the clinical scenario presented in image.png and the multiple-choice options in image_2.png, the correct clinical answer is ENT consult (or an elective postponement/evaluation if the case is not an emergency).
Here is a breakdown of why this is the case and why the other options fail:
1. The Core Problem: Fixed Subglottic/Laryngeal Stenosis
The prompt in image.png describes a patient with a known history of childhood inhalation injury and laryngeal stenosis who has not been evaluated by an otolaryngologist (ENT) in several years.
Looking closely at the CT scan images provided in image.png:
The Sagittal View (Left): Shows a severe, critical, and focal narrowing of the upper airway just below the vocal cords (subglottic stenosis).
The Axial View (Right): Confirms an incredibly tiny lumen (cross-sectional area) for airflow.
Because this is a structural, rigid narrowing (stenosis) rather than an anatomical variant or a soft-tissue obstruction, standard airway algorithms are severely altered.
2. Why "ENT Consult" is the Correct Answer
The "Cannot Ventilate, Cannot Intubate" Risk: If you induce anesthesia in this patient, a normal-sized endotracheal tube (ETT) will not pass through that stenosis. Worse, forcing a tube through can cause complete airway edema, rupture, or bleeding.
Surgical Airway Back-up: If this surgery is elective, it should be postponed until an ENT evaluates the airway, determines the diameter of the stenosis, and coordinates the plan. If the surgery must proceed, an ENT must be in the room ready to perform an emergency rigid bronchoscopy, jet ventilation, or a surgical tracheostomy downstream of the stenosis if things go wrong.
3. Why the Other Options are Incorrect or Tongue-in-Chief
Awake Fiberoptic Intubation (Incorrect): While awake fiberoptic intubation is the golden standard for a difficult-to-visualize airway (like a small jaw or stiff neck), it does not bypass a fixed structural narrowing. A fiberoptic scope might be able to look at the hole, but the endotracheal tube parked behind it will still hit a brick wall. Furthermore, topically anesthetizing and manipulating a critically narrow airway can trigger laryngospasm or swelling, completely shutting off the patient's remaining airway.
DL (Direct Laryngoscopy) with a Miller 4 (Incorrect): This is a recipe for disaster. A Miller 4 is a very long, straight blade used to lift the epiglottis. While it might give you a view of the vocal cords, it does nothing to help you pass a tube through a subglottic stenosis. Attempting blind or forceful pushing will completely compromise the airway.
The Bottom Three Options: Options like "Cancel and grab some breakfast," "Report the 'correct' answer to the Doximity editorial team," and "Call the cops" (seen in image_2.png) are satirical options added by the user on the Student Doctor Network forum. They are poking fun at the question's origin (likely a flawed or controversial "Case of the Month" quiz originally published on Doximity, where the official "key" may have frustratingly argued for an option that real-world anesthesiologists heavily disagree with!).
“
Based on the clinical scenario presented in image.png and the multiple-choice options in image_2.png, the correct clinical answer is ENT consult (or an elective postponement/evaluation if the case is not an emergency).
Here is a breakdown of why this is the case and why the other options fail:
1. The Core Problem: Fixed Subglottic/Laryngeal Stenosis
The prompt in image.png describes a patient with a known history of childhood inhalation injury and laryngeal stenosis who has not been evaluated by an otolaryngologist (ENT) in several years.
Looking closely at the CT scan images provided in image.png:
The Sagittal View (Left): Shows a severe, critical, and focal narrowing of the upper airway just below the vocal cords (subglottic stenosis).
The Axial View (Right): Confirms an incredibly tiny lumen (cross-sectional area) for airflow.
Because this is a structural, rigid narrowing (stenosis) rather than an anatomical variant or a soft-tissue obstruction, standard airway algorithms are severely altered.
2. Why "ENT Consult" is the Correct Answer
The "Cannot Ventilate, Cannot Intubate" Risk: If you induce anesthesia in this patient, a normal-sized endotracheal tube (ETT) will not pass through that stenosis. Worse, forcing a tube through can cause complete airway edema, rupture, or bleeding.
Surgical Airway Back-up: If this surgery is elective, it should be postponed until an ENT evaluates the airway, determines the diameter of the stenosis, and coordinates the plan. If the surgery must proceed, an ENT must be in the room ready to perform an emergency rigid bronchoscopy, jet ventilation, or a surgical tracheostomy downstream of the stenosis if things go wrong.
3. Why the Other Options are Incorrect or Tongue-in-Chief
Awake Fiberoptic Intubation (Incorrect): While awake fiberoptic intubation is the golden standard for a difficult-to-visualize airway (like a small jaw or stiff neck), it does not bypass a fixed structural narrowing. A fiberoptic scope might be able to look at the hole, but the endotracheal tube parked behind it will still hit a brick wall. Furthermore, topically anesthetizing and manipulating a critically narrow airway can trigger laryngospasm or swelling, completely shutting off the patient's remaining airway.
DL (Direct Laryngoscopy) with a Miller 4 (Incorrect): This is a recipe for disaster. A Miller 4 is a very long, straight blade used to lift the epiglottis. While it might give you a view of the vocal cords, it does nothing to help you pass a tube through a subglottic stenosis. Attempting blind or forceful pushing will completely compromise the airway.
The Bottom Three Options: Options like "Cancel and grab some breakfast," "Report the 'correct' answer to the Doximity editorial team," and "Call the cops" (seen in image_2.png) are satirical options added by the user on the Student Doctor Network forum. They are poking fun at the question's origin (likely a flawed or controversial "Case of the Month" quiz originally published on Doximity, where the official "key" may have frustratingly argued for an option that real-world anesthesiologists heavily disagree with!).
Would you look at that
Btw, the left image looks likely to be a ****ty slice at the level of the vocal cords. You look at any normal airway, and it’ll look like that on CT.
ENT Consult and Radiologist to tell me the actual diameter of the subglottic stenosis. This is a high risk case which requires a discussion preoperatively about the risks/benefits including a tracheostomy.
While I have not performed an anesthetic on critical subglottic stenosis I have used the Hunsaker and Jet Ventilation in similar scenarios.
pubmed.ncbi.nlm.nih.gov
Airway management and anesthesia for laryngeal surgery poses many challenges. A preoperativeendoscopic airway examination and discussion with the otolaryngologist helps in planning the anesthetic management. Although, securing the airway using specialized endotracheal tubes is possible inthe majority of cases, the surgeon may occasionally request a “tubeless” field. This can be achievedby ventilating the lungs using jet ventilation or high flow nasal oxygen (HFNO) while providing total intravenous anesthesia. Therefore, in addition to the “difficult airway” cart, equipment to provideHFNO and a high-pressure source of oxygen to provide jet ventilation should also be available.
While I have not performed an anesthetic on critical subglottic stenosis I have used the Hunsaker and Jet Ventilation in similar scenarios.
The Hunsaker Mon-Jet tube with jet ventilation is effective for microlaryngeal surgery - PubMed
Subglottic ventilation via the Hunsaker Mon-Jet tube with an automated jet ventilator may be considered an effective, safe and versatile technique for the anesthetic management of microlaryngeal surgery.
pubmed.ncbi.nlm.nih.gov
Airway management and anesthesia for laryngeal surgery poses many challenges. A preoperativeendoscopic airway examination and discussion with the otolaryngologist helps in planning the anesthetic management. Although, securing the airway using specialized endotracheal tubes is possible inthe majority of cases, the surgeon may occasionally request a “tubeless” field. This can be achievedby ventilating the lungs using jet ventilation or high flow nasal oxygen (HFNO) while providing total intravenous anesthesia. Therefore, in addition to the “difficult airway” cart, equipment to provideHFNO and a high-pressure source of oxygen to provide jet ventilation should also be available.
Last edited:
Anesthetic Management of a Patient with Severe Post-tracheostomy Stenosis - PMC
Anesthetic management of cases of post-tracheostomy stenosis is challenging for most of the anesthesiologists. We are describing a case of severe post-tracheostomy stenosis and its management using Hunsaker Mon-Jet laser resistant tube. Keywords: ...
pmc.ncbi.nlm.nih.gov
Arch Guillotti
Senior Member
Staff member
Administrator
Volunteer Staff
Lifetime Donor
20+ Year Member
This case is an outlier since there is a shelf/web rather than a simple stenosis and should only be fixed by a super-specialist. A "shelf" may not need to be fixed but should always be evaluated by an ENT. I have seen at least a thousand tracheal dilations which are almost always straightforward. If you run into a stenosis unexpectedly you have several options. You may think this can never happen to you but I have had several fellow anesthesiologists that have run into it. Cancel the case and wake them up. You should still be able to ventilate the patient. Intubate the patient with a smaller tube, do the case and leave them intubated afterwards. You should be able to corkscrew a 5.0 ETT, maybe even a 6.0. Always corkscrew, never push through. I know folks that have done both. I also have seen a pt. code during endoscopy. You are a fool if you knowingly proceed with a known stenosis unless it is a dire emergency.Anesthetic Management of a Patient with Severe Post-tracheostomy Stenosis - PMC
Anesthetic management of cases of post-tracheostomy stenosis is challenging for most of the anesthesiologists. We are describing a case of severe post-tracheostomy stenosis and its management using Hunsaker Mon-Jet laser resistant tube. Keywords: ...
