Airway management in a patient with cavernous hemangioma of the hypopharynx and larynx

A 48-year-old woman was diagnosed with cavernous hemangioma of hypopharynx and larynx, which extended to the trachea and mediastinum. She was scheduled for tracheostomy and open surgical excision of hypopharynx hemangioma under general anesthesia. On induction of anesthesia, we planned awake fiberoptic intubation according to the difficult airway algorithm of the American Society of Anesthesiologists. Under continuous infusion of remifentanil at 0.1-0.2 μg· kg^-1·min^-1, the patient became sedated while spontaneously breathing, and her pain and laryngeal reflexes were reduced. Although tracheal intubation was successfully accomplished without injuring the hypopharynx hemangioma, tracheostomy was difficult because of bleeding from the surgical site. After 3hr of surgery with 1,880g of blood loss, the surgeons quitted tracheostomy and the patient was transferred to the intensive care unit. Her airway was managed with endotracheal tube for 7 days, and open surgical excision of hypopharynx hemangioma was performed on day 7. The patient was successfully extubated on day 9 with the support of non-invansive positive pressure ventilation. Awake fiberoptic intubation under remifentanil infusion is safe and useful approach for patients with airway hemangioma.