ankylosing spondylitis is a chronic , autoimmune and progressive spondyloarthropathy affecting the spine and sacroiliac joints .
involvement of the cervical joints , temporomandibular joints and cricoarytenoid joints in these patients may cause difficulty during intubation .
although there are various options available for securing the airway in these patients , ranging from awake fibreoptic intubation to surgical tracheostomy , the management depends on the patient , the clinical setting and the skills of the anaesthesiologist .
awake fibreoptic intubation is the gold standard for known difficult airways , but patient refusal is a limitation for its use .
because the literature is scanty about the use of airtraq in the airway management of patients with severe ankylosing spondylitis , these two reports of patients planned for general anaesthesia will reveal the further scope of airway management .
the airtraq is a recently introduced optical airway device to facilitate tracheal intubation in patients with both normal and difficult airways .
the device provides a high - quality view of the glottis without the need to align the oral , pharyngeal and tracheal axes .
one channel acts as a conduit for passing the endotracheal tube ( ett ) while the other channel consists of an optical system that transfers the image from the illuminated tip to a proximal viewfinder .
the airtraq is anatomically shaped and standard ett of all sizes can be used using different sizes of airtraq .
we describe two cases with severe anylosing spondylitis who were successfully intubated using an airtraq laryngoscope .
a 40 year - old male , a known case of ankylosing spondylitis for 15 years , was scheduled for right total hip replacement for avascular necrosis of the head of femur .
on pre - anaesthetic examination , the patient had thoracolumbar kyphosis with restriction of movements in the dorsolumbar and lumbosacral spine .
the patient was unable to lie supine and required pillows beneath the head and neck for support .
x - ray lumbar spine revealed squaring of vertebra , calcification of anterior and posterior longitudinal ligaments and reduced interspinous spaces and fusion of the posterior elements at all levels .
airway assessment revealed a restricted mouth opening with interincisor gap of 1.9 cm and mallampati grade iv .
he was unable to extend his neck , with a steromental distance of 10.2 cm and thyromental distance of 5.4 cm .
the patient was planned for general anaesthesia as the patient did not give consent for awake fibreoptic intubation .
the patient was explained the possibility of difficult airway and consent for possible surgical tracheostomy was taken . on the day of surgery ,
the patient was premedicated with intravenous ( i.v . ) midazolam 2 mg and intramuscular ( i.m . )
the patient was made to lie supine with the head supported with pillows and all the standard monitors were applied .
and fentanyl 1 g / kg . after confirming adequate bag mask ventilation , neuromuscular relaxation
as the airtraq handle is comparatively larger and the patient neck movement was severely compromised , the table was adjusted to the head - down position with flexion of both the knees to facilitate the introduction of airtraq in the oral cavity .
the blade of the airtraq laryngoscope was introduced into the oral cavity in the midline over the base of the tongue and the tip was positioned in the vallecula .
the trachea was intubated with a size 8.0 mm tracheal tube in the first attempt after adequate visualisation of the vocal cords , which required minor adjustments of airtraq .
anaesthesia was maintained with nitrous oxide ( 66% ) and sevoflurane ( 12% ) in oxygen and vecuronium bromide .
the intraoperative course was uneventful and at the end of surgery neuromuscular blockade was reversed with i.v .
the patient was extubated and shifted to the post - anaesthesia care unit . a 65-year - old female patient , a known case of ankylosing spondylitis for 25 years ,
airway examination revealed a restricted mouth opening with interincisor gap of 1.8 cm and mallampatti grade iii .
indirect laryngoscopy could not be performed due to restricted mouth opening and limitation of neck mobility .
x - ray cervical spine showed gross osteopenia with complete fusion of posterior elements with end - plate sclerosis and decreased joint space at the c4-c5 and c5-c6 levels .
patient was planned for general anaesthesia as she did not give consent for awake fibreoptic intubation .
on the day of surgery , after written consent , the patient was premedicated with i.v .
glycopyrrolate 0.2 mg . the patient was made to lie supine with the head supported by four pillows and all the standard monitors were applied .
the blade of the airtraq laryngoscope was introduced into the oral cavity in the midline over the base of the tongue and the tip was positioned in the vallecula .
the trachea was intubated with a size 7.0 mm tracheal tube in the first attempt after centralizing the glottic opening in the view field , which required minor adjustments of airtraq and side - to - side wrist movement .
anaesthesia was maintained with 66% nitrous oxide in oxygen and 1% sevoflurane and vecuronium bromide .
surgery was uneventful and at the end of surgery , neuromuscular blockade was reversed with i.v .
the patient had a smooth recovery and was shifted to the post - anaesthesia care unit for further management .
a 40 year - old male , a known case of ankylosing spondylitis for 15 years , was scheduled for right total hip replacement for avascular necrosis of the head of femur .
on pre - anaesthetic examination , the patient had thoracolumbar kyphosis with restriction of movements in the dorsolumbar and lumbosacral spine .
the patient was unable to lie supine and required pillows beneath the head and neck for support .
x - ray lumbar spine revealed squaring of vertebra , calcification of anterior and posterior longitudinal ligaments and reduced interspinous spaces and fusion of the posterior elements at all levels .
airway assessment revealed a restricted mouth opening with interincisor gap of 1.9 cm and mallampati grade iv .
he was unable to extend his neck , with a steromental distance of 10.2 cm and thyromental distance of 5.4 cm .
the patient was planned for general anaesthesia as the patient did not give consent for awake fibreoptic intubation .
the patient was explained the possibility of difficult airway and consent for possible surgical tracheostomy was taken . on the day of surgery ,
the patient was premedicated with intravenous ( i.v . ) midazolam 2 mg and intramuscular ( i.m . )
the patient was made to lie supine with the head supported with pillows and all the standard monitors were applied .
and fentanyl 1 g / kg . after confirming adequate bag mask ventilation , neuromuscular relaxation
as the airtraq handle is comparatively larger and the patient neck movement was severely compromised , the table was adjusted to the head - down position with flexion of both the knees to facilitate the introduction of airtraq in the oral cavity .
the blade of the airtraq laryngoscope was introduced into the oral cavity in the midline over the base of the tongue and the tip was positioned in the vallecula .
the trachea was intubated with a size 8.0 mm tracheal tube in the first attempt after adequate visualisation of the vocal cords , which required minor adjustments of airtraq .
anaesthesia was maintained with nitrous oxide ( 66% ) and sevoflurane ( 12% ) in oxygen and vecuronium bromide .
the intraoperative course was uneventful and at the end of surgery neuromuscular blockade was reversed with i.v .
a 65-year - old female patient , a known case of ankylosing spondylitis for 25 years , was scheduled for subtotal thyroidectomy for colloid goitre .
airway examination revealed a restricted mouth opening with interincisor gap of 1.8 cm and mallampatti grade iii .
indirect laryngoscopy could not be performed due to restricted mouth opening and limitation of neck mobility .
x - ray cervical spine showed gross osteopenia with complete fusion of posterior elements with end - plate sclerosis and decreased joint space at the c4-c5 and c5-c6 levels .
patient was planned for general anaesthesia as she did not give consent for awake fibreoptic intubation .
on the day of surgery , after written consent , the patient was premedicated with i.v .
the patient was made to lie supine with the head supported by four pillows and all the standard monitors were applied .
the blade of the airtraq laryngoscope was introduced into the oral cavity in the midline over the base of the tongue and the tip was positioned in the vallecula .
the trachea was intubated with a size 7.0 mm tracheal tube in the first attempt after centralizing the glottic opening in the view field , which required minor adjustments of airtraq and side - to - side wrist movement .
anaesthesia was maintained with 66% nitrous oxide in oxygen and 1% sevoflurane and vecuronium bromide .
surgery was uneventful and at the end of surgery , neuromuscular blockade was reversed with i.v .
the patient had a smooth recovery and was shifted to the post - anaesthesia care unit for further management .
ankylosing spondylitis affects about 1% of men and 0.5% of women , with a peak age of onset between 20 and 30 years .
the cervical spine is involved late in the disease leading to restriction of the neck movement and head rotation causing non - alignment of the oral , pharyngeal and laryngeal axes . moreover ,
involvement of the atlanto - occipital joint , temporomandibular joint and cricoarytenoid joints leads to a potentially difficult airway situation .
various options are presently available for intubation in difficult airway , but these options get reduced in patients with restricted neck movements and limited mouth opening .
awake fibreoptic intubation is considered the safest option ; however , some patients may refuse being awake and prefer general anaesthesia during intubation .
we initially planned for awake fibreoptic intubation in our cases , but the patients were apprehensive about the procedure and refused to remain awake .
lai et al . reported glidescope to be a useful device for visualising the larynx and facilitating nasotracheal intubation in patients with ankylosing spondylitis . in their study , glidescope improved visualisation of larynx in 11 patients and intubation was successful in eight patients .
airtraq laryngoscope is a newly introduced single - use intubation device , simple to use and has got an easy learning curve that does not require hyperextension of the neck hence is useful for patients with cervical spine injury also .
it is inserted into the midline in the oral cavity loaded with polyvinyl chloride tracheal tube into the valeculla and after visualizing the glottic opening the airtraq blade is adjusted with a fine wrist movement to centralize the glottic opening over the eyepiece of the airtraq .
it does not obstruct the endoscopic view of the vocal cord during laryngoscopy because of its inbuilt conduit for the tracheal tube .
studies have reported the effectiveness and utility of the airtraq for tracheal intubation in patients with cervical spine immobilization and in morbidly obese patients .
but , this device has got the limitation of inbuilt conduit meant for tracheal tube that can not be manipulated in the conduit .
direct manipulation of the tube is not possible and the entire device has to be tilted and oriented with the tracheal tube in situ .
also , it can not be introduced into a mouth opening less than 16 mm for size 2 airtraq and 18 mm for size 3 airtraq .
however , there is a relative scarcity of the literature on the use of this device for intubation in patients of ankylosing spodylitis .
in a case series of four patients with difficult airway reported successful awake intubation using airtraq laryngoscope .
also used airtraq successfully as rescue device following failed awake fibreoptic intubation in a patient with severe ankylosing spondylitis .
we used airtraq successfully for intubation in our patient keeping in view restricted neck movements and non - alignment of the three axes , i.e. oral , pharyngeal and laryngeal .
neuroaxial anaesthesia was not planned in the first patient because of limited joint spaces and improper positioning of the patient .
neuroaxial anaesthesia in such patients may be technically difficult although not impossible due to limited joint mobility and reduced joint spaces .
we therefore conclude that intubation with airtraq is a good alternative for elective intubation in patients of ankylosing spondylitis who refuse awake fibreoptic intubation or if functional fibreoptic bronchoscope is not available .
 airway management in patients of ankylosing spondylitis remains a challenge for anaesthesiologists . 
 many new airway devices have been used for securing airway in these patients . 
 the airtraq optical laryngoscope is one of the new rigid laryngoscopes with a proximal view finder that reflects an image transferred from the distal tip of the blade through a series of lenses , prisms and mirrors . 
 we report two cases of ankylosing spondylitis who were scheduled for total hip replacement and subtotal thyroidectomy and were successfully intubated using the airtraq laryngoscope . 
INTRODUCTION
CASE REPORT
Case 1
Case 2
DISCUSSION
CONCLUSION