Airway management in a patient with a deep neck abscess and tortuous brachiocephalic artery: Case report and review of the literature

Endotracheal intubation and tracheotomy under local anesthesia are available methods to maintain an adequate airway in patients with deep neck abscess; but neither of them is easy to perform. We report a case of deep neck abscess with a tortuous brachiocephalic artery in which massive hemorrhage from the pharynx occurred during endotracheal intubation. A 79-year-old man presented to our department with cervical swelling, hoarseness, and difficulty in swallowing. CT scans revealed abscesses associated with gas in the left submandibular space, left parapharyngeal space, and bilateral anterior cervical space. The brachiocephalic artery ran horizontally immediately beneath the thyroid gland on the anterior surface of the trachea. We decided to perform surgery under general anesthesia. Endotracheal intubation was selected to maintain an adequate airway, because tracheotomy was considered to be risky due to the high location of the brachiocephalic artery. Hemorrhage from the pharynx occurred immediately after insertion of a tracheal tube into the pharyngeal cavity. Bleeding was controlled by packing the pharyngeal cavity with gauze, after which the tube could be advanced into the trachea. Incisional drainage of the abscesses and debridement of necrotic tissue were performed. The patient was discharged from hospital 63 days postoperatively.