LAUSR

Anesthesiology, V 128 • No 6 1239 June 2018 L ARYNGEAL papillomatosis is a rare condition.1 The image presented is from a 60-yr-old female with a 5-yr history of dysphagia and progressive dyspnea who presented to an outside hospital for pharyngeal biopsy. Intraoperatively, she had complete airway obstruction, an urgent tracheostomy was performed, and she was transferred to our institution for definitive management. See image of intraoperative laryngoscopy demonstrating the exophytic and proliferative growth of laryngeal papillomatosis lesions that contribute to the risk of complete airway obstruction. Perioperatively, patients with laryngeal papillomatosis are at risk for hypoventilation, hypoxemia, or airway loss. Hence, ventilation technique choice balances potential obstruction (i.e., paralytic agent causing pharyngeal muscle relaxation) and the need for a relatively unobstructed and still surgical field. When no tracheostomy is in place, ventilation is typically conducted via one of four techniques: spontaneous ventilation, controlled mechanical ventilation, jet ventilation, or apnea with intermittent ventilation. If risk of airway obstruction is minimal, then typical induction and intubation with a downsized endotracheal tube (ETT) is feasible; intermittent ETT removal with apneic periods may be needed for surgical view as well to diminish airway fire risk with laser use.2 Jet ventilation advantages include the ability to be performed supraglottic or subglottic (transglottic or transtracheal) using a variety of conduits (i.e., ETTs, rigid catheters) selected to minimize obscuring of the surgical field.3 Jet ventilation increases the risk of barotrauma (pneumothorax, pneumomediastinum) and exhalation needs to be assured. If complete airway obstruction occurs, emergent partial removal of some papillomatosis tissue may permit the resumption of ventilation obviating the need for tracheostomy.