Transnasal Videoendoscopy for Preoperative Airway Risk Stratification: Development and Validation of a Multivariable Risk Prediction Model

Abstract

BACKGROUND: Transnasal flexible videoendoscopy (TVE) of the larynx is a standard of care for the detection and staging of pharyngolaryngeal lesions in otorhinolaryngology. Patients frequently present with existing TVE examinations before anesthesia. Although these patients are considered high risk, the diagnostic value of TVE for airway risk stratification is currently unknown. How can captured images or videos be used for anesthesia planning, and which lesions are most concerning? This study aimed to develop and validate a multivariable risk prediction model for difficult airway management based on TVE findings and to determine whether the discrimination of the Mallampati score can be improved by adding this new TVE model. METHODS: This retrospective single-center development and validation study assessed 4021 patients who underwent 4524 otorhinolaryngologic surgeries at the University Medical Centre Hamburg-Eppendorf between January 1, 2011, and April 30, 2018, with electronically stored TVE videos and included 1099 patients who underwent 1231 surgeries. TVE videos and anesthesia charts were systematically reviewed in a blinded fashion. The Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis was used for variable selection, model development, and cross validation. RESULTS: The prevalence of difficult airway management was 24.7% (304/1231). Lesions at the vocal cords, epiglottis, or hypopharynx were not selected by the LASSO regression, while lesions at the vestibular folds (ß-coefficient 0.123), supraglottic region (ß-coefficient 0.161), arytenoids (ß-coefficient 0.063), and viewing restrictions on the rima glottidis that cover ≥50% of the glottis area (ß-coefficient 0.485) and pharyngeal secretion retention (ß-coefficient 0.372) were relevant risk factors for difficult airway management. The model was adjusted for sex, age, and body mass index. The area under the receiver operating characteristic curve (95% confidence interval) of the Mallampati score was 0.61 (0.57–0.65) and 0.74 (0.71–0.78) of the TVE model combined with Mallampati ( P < .001). CONCLUSIONS: Stored images and videos from TVE examinations can be reused for the purpose of predicting risk associated with airway management. Vestibular fold, supraglottic, and arytenoid lesions are most concerning, especially if they are accompanied by secretion retention or restrict the glottic view. Our data indicate that the TVE model improves discrimination of the Mallampati score and might, therefore, be a useful addition to traditional bedside airway risk examinations.

Trends in Preoperative Airway Assessment

“…However, convincing evidence on the usefulness of a preoperative endoscopy in the general population requiring general anesthesia is lacking. Still, there has been increasing interest in the matter as fiberoptic technology has become available, and a few studies have shown that transnasal fiberoptic airway assessments could improve the predictability of routine airway examinations regarding conventional laryngoscopy or videolaryngoscopy [ 29 , 30 , 31 ].…”

“…Flexible rhinolaryngoscopy is not used to its full potential in anesthesia, intensive care, or emergency departments, despite recommendations in guidelines to consider it in patients with possible airway pathology of a tumoral, inflammatory, or traumatic nature that could preclude mask ventilation and impede the placement of a supraglottic device or an intubating tube [ 10 , 28 ]. Its utility in assessing anatomically difficult airways is yet to be determined, but a few studies have shown its benefit [ 29 , 30 ]. As technology progresses, this device will become handier, more affordable, and provide sharper images, and patients rate it as having good procedure tolerability.…”

Comparaison du dispositif Vie Scope® et de la vidéolaryngoscopie pour la prise en charge de voies aériennes difficiles anticipées : une étude randomisée contrôlée

“… 11 – 13 Only patients with indicators for difficult tracheal intubation, such as a SARI ≥ 4 points, Wilson score ≥ 2 points, a positive ULBT, relevant pharyngolaryngeal lesions, reported previous difficult tracheal intubations (e.g., anesthesia alert card or a videolaryngoscopic intubation and difficult airway classification [VIDIAC] score ≥ 2), or a combination of these factors were considered eligible for study inclusion. 5 , 11 , 13 – 16 Furthermore, patients were checked for indicators for awake tracheal intubation using a previously recommended decision-making tool taking predictors for difficult tracheal intubation, suspected difficult facemask and/or supraglottic-airway ventilation, physiologic issues such as apnea intolerance, risk for aspiration and hemodynamic instability, and contextual issues into account. 2 Patients that qualified for awake tracheal intubation or required a nasotracheal intubation, special tubes such as laser or microlaryngoscopy tubes, rapid-sequence induction, or had loose teeth were excluded.…”

Hyperangulated blades or direct epiglottis lifting to optimize glottis visualization in difficult Macintosh videolaryngoscopy: a non-inferiority analysis of a prospective observational study

“…Adults who presented at our Anesthesia Preassessment Clinic before elective ear, nose and throat or oral and maxillofacial surgery between April 1, 2019 and April 3, 2020 were assessed for eligibility. All patients received a structured preoperative airway risk assessment in accordance with standards laid out by the Department of Anesthesiology that comprises clinical history and physical examinations [such as the upper lip bite test, the simplified airway risk index and flexible nasendoscopy ( 28 , 29 ) if appropriate] ( 30 , 31 ). Details are reported elsewhere ( 11 ).…”