Unexpected Difficult Tracheal Intubation Caused by A Laryngeal Cyst in A Child Undergoing Emergency Laparotomy
Dr. Aariz Javed Ansari 1, Dr. Parmanand Mandawaria *2, Dr. Sony Baby 3
*Correspondence to: Dr. Parmanand Mandawaria, Consultant Anaesthetist, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates.
Copyright.
© 2026 Dr. Parmanand Mandawaria, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 05 October 2026
Published: 01 November 2026
DOI: https://doi.org/10.5281/zenodo.23906315
Abstract
In some cases, the assessment of a child's airway in an emergency is inadequate, and normal external appearances do not rule out the possibility of an internal lesion which interferes with tracheal intubation.
Case presentation: A six-year-old boy who had a developmental delay had an emergency exploratory laparotomy because of pneumoperitoneum caused by gastric perforation. He was drowsy and it was not possible to carry out a Mallampati grading. After general anaesthesia was induced, bag-mask ventilation proved straightforward (Apfelbaum et al., 2022, pp. 31-81), but direct laryngoscopy showed a large cystic lesion blocking the view of the glottis and the first a (Kariya et al., 2003, pp. 534-536) attempt at intubation therefore failed. Bag-mask ventilation was then restarted. Using a C-MAC video laryngoscope the view was improved; the lesion was gently moved laterally so that the posterior vocal cords could be seen and a styled endotracheal tube with an internal diameter of 5.0 mm was inserted. The correct position of the tube was confirmed both by visual confirmation and by waveform capnography. The gastric perforation was repaired by primary closure. Since there was a concern that obstruction might occur when the child came out of anaesthesia, he remained intubated and was transferred to the paediatric intensive care unit. The otolaryngology team removed the cyst the following day after which he was successfully extubated. After extubation he developed bradycardia which led to endocrine assessment and Holter monitoring. He then improved and was discharged on postoperative day 5.
Conclusion: Because effective mask ventilation had been achieved, the patient could be reassessed following a failed direct laryngoscopy and successful intubation was then accomplished with the use of an alternative device. Otolaryngological involvement together with continued postoperative airway protection permitted planned extubation after the lesion had been treated.
Keywords: paediatric difficult airway; laryngeal cyst; emergency laparotomy; video laryngoscopy; tracheal intubation; extubation.
Introduction
If there is an unexpected problem with tracheal intubation, it is necessary to have a strategy in place which ensures that oxygenation (George et al., 2022) is maintained while the clinician investigates the reason for the failure. Current guidance on difficult airways covers both (Apfelbaum et al., 2022, pp. 31-81) adult and paediatric cases and stresses the importance of having access to alternative techniques, taking account of the number of attempts made, and being prepared for extubation [1]. There are also specific algorithms for children's cases which deal with unexpected difficulties in children between 1 and 8 years of age [2].
A lesion in the airway may not show up when the individual is examined from the outside, a situation (Chrimes et al., 2022, pp. 1395-1415) which is especially important in emergency surgery since the patient's reduced level of consciousness or lack of cooperation makes it impossible to carry out a full assessment. We report a case of a child in whom a laryngeal cyst that had previously gone unnoticed caused difficulties with direct laryngoscopy at the time of induction for an emergency laparotomy. The main point of the case is the shift to the use of video laryngoscopy and the subsequent strategy for airway management and extubation.
Case Presentation
Presentation and surgical indication
A six-year-old boy was brought from another hospital via the emergency department having had acute abdominal pain for one day, with the condition having worsened over time, together with poor oral intake and constipation. He was appearing drowsy. His medical history had included a suspected autism spectrum disorder, global developmental delay, and chronic abdominal distension and constipation. Earlier genetic testing had detected a homozygous variant of uncertain significance in ALDH18A1, specifically c.512C>T, p.(Ala171Val). This result formed part of his initial evaluation and no link was found between it and the airway lesion.
The abdominal X-ray reported the presence of pneumoperitoneum, which led to concern regarding a perforated viscus. An emergency exploratory laparotomy was arranged as a Level 1 emergency operation. During the surgery a gastric perforation was found, and this was repaired by primary repair. A portable radiograph that was supplied is given in Figure 1.
Preoperative preparation
When the child arrived in the operating room, he was drowsy and his vital signs were said to be borderline. Although his external facial appearance was normal, a Mallampati score could not be obtained. There was already a 22-gauge intravenous cannula in his left hand.
Electrocardiography, pulse oximetry and non-invasive blood pressure monitoring were carried out. The airway equipment, including that on the difficult-airway cart, was prepared.
Unexpected intubation difficulty and rescue
The patient was preoxygenated for three minutes using 100% oxygen after which general anaesthesia was administered. Bag-mask ventilation proved to be straightforward. When carrying out direct laryngoscopy, a large cystic lesion was found which blocked the view of the glottis and made conventional intubation impossible. This lesion is stated in the clinical report to be situated infraglottically. The photographs of the airway are given in Figures 2 and 3.
After the first attempt had failed, bag-mask ventilation was restarted. To get a better view, a C-MAC video laryngoscope was employed. The cyst was gently laterally displaced to expose the back part of the vocal cords. A 5.0-mm internal diameter endotracheal tube, which had a stylet in it, was carefully passed through the available space into the trachea. The correct position of the tube was verified by direct visual inspection and by the presence of a capnographic waveform.
Postoperative airway management
Since there was a possibility that the lesion could lead to an obstruction either during emergence or after the endotracheal tube was removed, the team decided to keep the child on mechanical ventilation. The child was then transferred, given a sedative and intubated, to the paediatric intensive care unit (PICU), and the otolaryngology team were consulted.
The next day the otolaryngology team removed the cyst, which led to relief of the obstruction. Once the airway had been assessed for patency and the patient found to be clinically ready, they were successfully extubated without any immediate airway problems.
Subsequent course and outcome
After the child was extubated, a persistent bradycardia appeared, the heart rate at first being in the 50s beats per minute. Thyroid function tests revealed low levels of free triiodothyronine and free thyroxine, and it was considered likely that the child had the euthyroid sick syndrome. The endocrinology department looked at the child and then started levothyroxine at a dose of 25 µg. A 24-hour Holter electrocardiographic monitoring was organised. The heart rate afterwards increased and reached the 60s beats per minute, coinciding with progressive clinical improvement. However, the sequence of events does not prove that the levothyroxine was the cause.
The rest of the time after the operation went smoothly. The child was able to start taking food, was moved from the PICU to the ward, and was sent home on day 5 after the operation.
Discussion
Recognition of an unexpected internal airway lesion
In this case the difference between difficulty with intubation and difficulty with ventilation was the key point. Although the cyst meant that adequate visualisation of the glottis could not be achieved during direct laryngoscopy, mask ventilation still worked. This enabled the team to stop proceedings, reestablish ventilation and alter their intubation method. The child's normal external facial appearance had not revealed the internal obstruction, and his drowsiness had prevented a proper preoperative (Heyes & Lott, 2017, pp. 928-939) assessment.
The designation "infraglottic" must be confirmed by an otolaryngology examination. The anatomical origin, the dimensions, and the final diagnosis of the cyst are not given in the case account provided. Although the photographs are available, they do not show the cyst's origin or its histological type. For these reasons, the more general term "laryngeal cyst" is employed here. Neither a congenital cause nor an association with a genetic variant can be deduced.
Changing technique after failed direct laryngoscopy
The guidance from the ASA places a focus on oxygen delivery and recommends limiting the number of attempts while also considering other airway techniques if difficulty is encountered [1]. The prospective registry analysis carried out by the PeDI showed that in children who had difficult intubation making more than two attempts at direct laryngoscopy was linked to a higher degree of complications [3]. This observational result indicates that it is advisable not to carry on with an approach that has failed; however, it does not state that a particular rescue device will be successful in every anatomical situation.
For this patient, the team switched to using video laryngoscopy since the first direct attempt had failed. The better view, combined with careful lateral displacement of the lesion, allowed the endotracheal tube to be inserted. However, this was a manoeuvre specific to the case and must not be understood as a general suggestion for manipulating an undiagnosed airway mass. Because there is no recorded lowest point of oxygen saturation, the time taken to complete the intubation, and a detailed record of the attempts, it is not possible to evaluate the physiological stress experienced during the rescue.
Planning extubation and specialist treatment
The fact that a successful intubation did not eliminate the worry about the cyst blocking the airway once the tube had been removed remained. Remaining intubated enabled the child to be assessed and treated in a controlled postoperative environment. According to the ASA guidelines, there is a planned strategy for extubation, involving an assessment of the patient's readiness and taking into account the setting and the available assistance [1]. The described sequence of care in the PICU, followed by otolaryngology aspiration and then extubation, shows that planning was carried out.
Aspiration was followed by a successful extubation during this hospital stay. The report, however, does not include any subsequent endoscopic findings, an assessment of cyst recurrence, or a histological diagnosis. It thus only describes early relief of the airway rather than setting out a definite long-term treatment. The later occurrence of bradycardia and the endocrine evaluation should also be kept separate from the airway event; the cause of these findings and the reason for initiating thyroid replacement must be confirmed by reference to the clinical records.
Conclusion
A laryngeal cyst that had not been previously recognised led to the failure of direct-laryngoscopic intubation in a child who was undergoing an emergency laparotomy. The patients' airway was successfully maintained using bag-mask ventilation, which allowed for a reassessment and subsequently successful C-MAC-assisted intubation. Following this, intubation was continued, the lesion was treated by specialists and extubation was planned, resulting in a favourable short-term outcome. This case highlights the importance of having an alternative intubation strategy and an extubation plan when abnormal airway conditions are encountered.
Reference