BACKGROUND: Unanticipated difficult airway management is a challenge for every anesthesiologist. We report the case of a patient with Waldeyer’s ring hypertrophy secondary to a lymphoma whose parapharyngeal involvement resulted in severe difficult airway management. This fact remained unnoticed in preoperative assessment.

CASE REPORT:A 86-year-old male patient, ASA III, diagnosed with lymphoma, was scheduled for a submaxillectomy to choose his best chemotherapy treatment. He had a medical history of hypertension, ischemic heart disease and lacunar infarct. He didn't have any surgical history. He referred nasal voice and prominent laterocervical adenopathies without respiratory symptoms.There were no risk predictors in preopeoperative airway assessment. Following anesthesic induction, mask ventilation was impossible (Han IV). First direct laryngoscopy was done, observing Cormack-Lehane Grade III, severe anatomic distortion and bleeding. After that,a more skilled anesthesiologist performed two videolaryngocopy attempts without any improvement. A suppraglottic airway device was then inserted in order to priorize oxygenation. Finally, successful intubation was achieved by performing a fiberoptic broncoscopy through the supraglottic device although glottis could not be correctly observed. We decided to delay extubation and patient was transferred to the Reanimation Unit. There were no incidences in extubation. TC imaging  seen after the procedure revealed a severe narrowing of parapharyngeal space due to Waldeyer’s ring hypertrophy.

DISCUSSION: Hypopharyngeal affection due to a lymphoma is an uncommon difficult airway’s ethiology. Its importance lies in the fact that it may go unnoticed in preoperative assessment, as happened to us. Moreover, pharyngheal pathology hinders fibrobronchoscopic and videolaryngoscopic intubation. Limiting airway manipulation is mandatory. Imaging test should be performed and evaluated in order to diagnose a possible difficult airway and elaborate a proper therapeutic approach.

LEARNING POINTS: Advanced lymphoprolipherative syndromes cause disseminated adenopathies whose pharapharyngeal involvement can lead to a difficult airway. Absence of risk predictors in preoperative airway assesment does not exclude it, so we should always consider imaging tests results in our preoperative airway assesment.

11 / Difficult airway in a patient with lymphoma