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LETTERS TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 35-37
 

Parotid swelling: An unseen predictor of upper airway edema following prolonged steep head down position


Department of Anaesthesiology and Critical Care, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Date of Web Publication22-May-2018

Correspondence Address:
Dr. Manoj Bhardwaj
Department of Anaesthesiology and Critical Care, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi - 110 085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_9_18

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How to cite this article:
Bhardwaj M, Mittal AK, Dubey J. Parotid swelling: An unseen predictor of upper airway edema following prolonged steep head down position. Indian Anaesth Forum 2018;19:35-7

How to cite this URL:
Bhardwaj M, Mittal AK, Dubey J. Parotid swelling: An unseen predictor of upper airway edema following prolonged steep head down position. Indian Anaesth Forum [serial online] 2018 [cited 2019 Oct 22];19:35-7. Available from: http://www.theiaforum.org/text.asp?2018/19/1/35/232918




Sir,

We report a case of postsurgical massive bilateral parotid glands swelling as an alarming sign of airway edema in a 70-year-old male patient who underwent robotic cystectomy with ureteric implantation and ileal conduit formation in steep head down position. In this case, we observed stertors along with bilateral parotid swelling. Although we managed the patient with supportive care without reintubation, it could be a valuable clinical marker of emerging airway edema. Among the various complications [1] associated with steep head down position during robotic-assisted laparoscopic surgery, we could not find the association of parotid swelling as an indicator of airway edema.

After the uneventful completion of surgery that lasted for more than 5 h, we noticed bilateral parotid swelling [Figure 1] with normal airway pressure (19 cm H2O). As the patient had stable hemodynamic and respiratory parameters, neuromuscular blockade was reversed, and the patient was extubated. Soon, he developed stertors though no respiratory distress was found and the patient was maintaining saturation (SpO2- 99%), on oxygenation through mask. After 5 min, as stertors were continuing, direct laryngoscopy was performed which revealed mild arytenoids edema with flabby motion of vocal cords causing the stertors. As there was no sign of respiratory distress was there, facemask oxygenation was continued along with nasal airway and propped-up position. Approximately after 30 min, stertors disappeared and 6 h later parotid swelling subsided on its own without any sequelae.
Figure 1: Bilateral parotid swelling seen in front and lateral view

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The reported incidence of airway edema in surgeries requiring steep Trendelenburg position ranges from 0.7% to 26% but no such incidence has ever been reported for parotid swelling. The proposed strategies for managing airway edema include head up position, application of continuous positive airway pressure, putting nasopharyngeal airway, extubation in head up position, intraoperative fluid restriction, and administration of diuretics.[2],[3] We also followed the same guidelines to prevent venous engorgement and airway edema by restricting the fluid infusion up to 200 ml in head down position. Even restricting fluid could not prevent airway edema which was managed with nasopharyngeal airway, oxygenation, and propped up position.

Parotid swelling, which was not present during preanaesthetic assessment, probably developed during the course of steep Trendelenburg and gradually increased in size. This swelling was missed during surgery and was identified only at the end of surgery, as the face was partially covered under the drapes. The possible reasons for parotid swelling could be impaired drainage of lymphatics and venous blood, retention of secretions, retrograde flow of air during coughing and straining, use of atropine and sympathomimetic drugs, and ischemia due to compression of arterial and venous supply of the gland.[4]

In this patient, due to old age and prolonged steep head down position, the impaired parotid gland venous or lymphatic drainage into the external jugular vein and upper cervical lymph nodes was the probable reason for swelling. Zolla et al.[5] have shown aging-related anatomical and biochemical changes in lymphatic collector system leading to impaired lymph transport and homeostasis. Loss of matrix proteins and smooth muscles and incompetent lymphatic valves in aged collectors resulted in decreased contraction frequency, systolic lymph velocity and pumping activity of venous lymphatic system, gravitational pull in steep head down position have the synergistic effect, leading to gland swelling. Retrograde flow of air was not possible as swelling appeared before extubation. Atropine or other sympathomimetic drugs were not used, and ischemia due to compression of arterial and venous supply of the gland could not have been the reason as neck was placed in midline without flexion and also because swelling was bilateral.

Chemosis and conjunctival edema have already been reported as a predictor of airway edema.[6],[7] We suggest the appearance of parotid swelling may be considered as an unseen predictor of airway edema, delayed extubation, and extubation failure. We propose cuff leak test [8] and check laryngoscopy to be performed before extubation, to identify the risk patients and to prevent related complications. Moreover, respiratory support should be continued till airway edema subsides.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Maerz DA, Beck LN, Sim AJ, Gainsburg DM. Complications of robotic-assisted laparoscopic surgery distant from the surgical site. Br J Anaesth 2017;118:492-503.  Back to cited text no. 1
[PUBMED]    
2.
Rewari V, Ramachandaran R. Prolonged steep trendelenburg position: Risk of postoperative upper airway obstruction. J Robot Surg 2013;7:405-6.  Back to cited text no. 2
    
3.
Oksar M, Akbulut Z, Ocal H, Balbay MD, Kanbak O. Robotic prostatectomy: The anesthetist's view for robotic urological surgeries, a prospective study. Rev Bras Anestesiol 2014;64:307-13.  Back to cited text no. 3
[PUBMED]    
4.
Baykal M, Karapolat S. A case of anesthesia mumps after general anesthesia. Acta Anaesthesiol Scand 2009;53:138.  Back to cited text no. 4
[PUBMED]    
5.
Zolla V, Nizamutdinova IT, Scharf B, Clement CC, Maejima D, Akl T, et al. Aging-related anatomical and biochemical changes in lymphatic collectors impair lymph transport, fluid homeostasis, and pathogen clearance. Aging Cell 2015;14:582-94.  Back to cited text no. 5
    
6.
Oksar M, Akbulut Z, Ocal H, Balbay MD, Kanbak O. Anesthetic considerations for robotic cystectomy: A prospective study. Braz J Anesthesiol 2014;64:109-15.  Back to cited text no. 6
[PUBMED]    
7.
Kilic OF, Börgers A, Köhne W, Musch M, Kröpfl D, Groeben H, et al. Effects of steep trendelenburg position for robotic-assisted prostatectomies on intra- and extrathoracic airways in patients with or without chronic obstructive pulmonary disease. Br J Anaesth 2015;114:70-6.  Back to cited text no. 7
    
8.
De Backer D. The cuff-leak test: What are we measuring? Crit Care 2005;9:31-3.  Back to cited text no. 8
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