79th PostGraduate Assembly in Anesthesiology 2025

Successful Cricothyroidotomy for Acute Epiglottitis with Super-Super Obese Patient

Brandon Wang, BA, Sung Hwa Dong, MD, PhD, Ahmed Treki, MD, Joon Kim, MD, Felix Sterling, MD, Erik Romanelli, MD, Kay Lee, MD

Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine

Introduction

Acute epiglottitis is a rapidly progressive and potentially fatal cause ofupper airway obstruction.
Prompt recognition and early airway management are essential toprevent complete airway collapse [1].
Obesity, particularly super-super obesity (BMI ≥ 60), presentssignificant challenges to airway visualization, patient positioning, andventilation [2].
This case demonstrates successful cricothyroidotomy afterfailed attempts atorotracheal intubation in apatient with severe upperairway obstructioncomplicated by extremebody habitus.

Background

Cricothyroidotomy is the definitive emergency surgical airway whennon-surgical attempts fail or when a “cannot intubate, cannotoxygenate” (CICO) scenario is reached [3].
Early transition to a surgical airway is associated with reduced morbidityin high-risk patients.

Indications include:

Severe upper airway obstruction (e.g., epiglottitis, laryngeal edema).
Failed intubation with worsening oxygenation.
Anatomical factors preventing laryngoscopy or supraglottic deviceplacement [4].

Challenges in super-obese patients:

Thick anterior neck tissue obscuring landmarks.
Increased difficulty achieving adequate bag-mask ventilation.
Rapid desaturation due to low pulmonary reserve [4].

Case Presentation

A 39-year-old male with asthma, hypertension, major depressive disorder, obstructivesleep apnea, and super-super obesity (BMI 66.5) presented with a 1-day history ofworsening sore throat, muffled voice, stridor, and inability to speak. He could not liesupine due to dyspnea.

Initial Management

Treated with dexamethasone, unasyn, NAC/albuterol, and IM epinephrine withtransient symptom improvement, however respiratory status continued to decline. Attempts at intubation using both GlideScope and fiberoptic bronchoscopy wereunsuccessful due to massive epiglottic swelling. Pulse ox dropped to 62% and temporary ventilation was achieved using an LMA withstrong chin-lift maneuver.

Definitive Airway

A cricothyroidotomy was performed emergently, successfully securing the airway with placement of an endotracheal tube. Patient was taken to the OR for tracheostomy, but was unsuccessful due to body habitus and deep trachea. On postoperative day (POD) 3, he underwent I&D for an epiglottal abscess and was successfully converted to orotracheal intubation. The patient was extubated on POD 10 and recovered without further airway complications.

Discussion

Delayed Presentation

Adult epiglottitis can progress gradually, leading to delayed care.
Late presentation increases risk of severe obstruction and need for surgicalairway [1].

Impact of Super-Super Obesity

Thick neck tissues obscure airway landmarks and hinder laryngoscopy.
Reduced functional reserve causes rapid desaturation.
Difficult mask ventilation and patient positioning further complicate airwaymanagement [2].

Cricothyroidotomy as Definitive Rescue

Intubation attempts failed despite GlideScope and fiberoptic bronchoscopy dueto severe epiglottic edema
Repeated attempts risk worsening swelling and hypoxia.
Emergent cricothyroidotomy is recommended in CICO scenarios.
Early transition to a surgical airway improves success and reduces hypoxicinjury [4].

Conclusion

This case highlights the life-saving role of cricothyroidotomy in acute upper airwayobstruction when conventional airway techniques fail, particularly in patients withsuper-super obesity. The combination of severe epiglottic swelling, difficultanatomy, and rapid desaturation made early transition to a surgical airway critical.This case underscores the importance of clinician proficiency in cricothyroidotomyand reinforces the need for early recognition and decisive action in airwayemergencies.

References

[1] Baxter FJ, Dunn GL. Acute epiglottitis in adults. Can J Anaesth. 1988;35(4):428-435. doi:10.1007/BF03010869

[2] Aceto P, Perilli V, Modesti C, Ciocchetti P, Vitale F, Sollazzi L. Airway management in obese patients. Surg ObesRelat Dis. 2013;9(5):809-815. doi:10.1016/j.soard.2013.04.013

[3] Ahmad I, El-Boghdadly K, Iliff H, et al. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. Br J Anaesth. Published online November 7, 2025. doi:10.1016/j.bja.2025.10.006

[4] Brown CA, III, Sakles JC, Mick NW. The Walls Manual of Emergency Airway Management, 5e. Lippincott Williams & Wilkins, a Wolters Kluwer bu; 2018.

[5] Chappell B. How To Do a Percutaneous Cricothyrotomy. MSD Manual Professional Edition. Published February 6, 2023. Accessed November 17, 2025.

79th PostGraduate Assembly in Anesthesiology 2025

Successful Cricothyroidotomy for Acute Epiglottis with Super-Super Obese Patient

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