Abstract / Summary
Abstract Background Renal osteodystrophy associated with long-term kidney disease and secondary hyperparathyroidism may result in skeletal deformities that potentially complicate airway management. Conventional bedside airway assessment may not fully identify airway-related risks in patients with marked skeletal abnormalities. We report the anesthetic management of a patient with long-term maintenance hemodialysis, secondary hyperparathyroidism, and severe skeletal deformity who was considered to have a potential difficult airway despite relatively reassuring conventional airway findings. Case presentation A 45-year-old man with a 25-year history of chronic kidney disease and maintenance hemodialysis was admitted for parathyroidectomy because of long-standing secondary hyperparathyroidism. Preoperative examination revealed marked thoracic kyphosis, skeletal deformities, and abnormal trunk posture. Although the patient had a Mallampati class II airway, approximately three-finger-breadth mouth opening, and relatively preserved neck extension, cervicothoracic computed tomography demonstrated severe kyphosis and abnormal spinal alignment. Three-dimensional airway reconstruction further demonstrated altered spatial relationships between the cervicothoracic skeletal structures and the airway axis. Considering the potential limitations of airway positioning and manipulation, an awake fiberoptic intubation strategy was selected. After adequate preoxygenation, mild sedation was achieved with midazolam and sufentanil while spontaneous ventilation was maintained. Topical airway anesthesia was performed using lidocaine spray and cricothyroid membrane puncture. Successful tracheal intubation was achieved under flexible bronchoscopic guidance before induction of general anesthesia. Multiple rescue strategies, including supraglottic airway devices, retrograde intubation equipment, and emergency front-of-neck airway access, were prepared in advance. General anesthesia and subsequent extubation were uneventful. Postoperative monitoring showed a transient decrease in serum calcium without clinical manifestations of hypocalcemia. Conclusions In patients with long-term dialysis and secondary hyperparathyroidism, marked skeletal deformities may indicate potential airway management challenges even when conventional airway assessment appears reassuring. Comprehensive evaluation of skeletal anatomy, body alignment, airway positioning, and rescue options may help identify occult airway risk. Awake fiberoptic intubation with preservation of spontaneous ventilation may provide a controlled approach when difficult airway management is anticipated. Postoperative calcium monitoring is also important after parathyroidectomy in patients with long-standing secondary hyperparathyroidism.