A 52-year-old female with rheumatoid arthritis and ankylosing spondylitis is scheduled for emergency cesarean section. Awake fiberoptic intubation is planned due to severely restricted neck mobility. The fiberscope is passed through the nose, and the vocal cords are identified. However, when the endotracheal tube is advanced over the scope, it catches at the level of the arytenoids and cannot be advanced further despite gentle traction. The fiberscope is still visible through the tube lumen. What is the most appropriate next step?

Explanation

## Problem Identification The tube is **impacted at the arytenoids**—a common complication during fiberoptic intubation, especially in patients with: - Limited neck mobility (ankylosing spondylitis) - Anterior larynx - Tight vocal cord anatomy The tube's bevel is catching on the arytenoid cartilage as it advances. ## Solution: Tube Rotation Maneuver **Key Point:** When a tube catches at the arytenoids during fiberoptic intubation, **rotating the tube 90° counterclockwise** (or clockwise, depending on which side is obstructed) redirects the bevel away from the arytenoid and allows passage. ### Why This Works - The endotracheal tube bevel is angled. Rotation changes the bevel orientation relative to the arytenoid cartilage. - A 90° rotation typically redirects the tube tip away from the obstruction. - The fiberscope remains in view, confirming the tube is still aligned with the airway. - This is a **gentle, non-traumatic maneuver** that preserves the airway. **High-Yield:** The "tube rotation" or "90° twist" is a standard rescue technique taught in fiberoptic intubation courses and is the **first-line maneuver for arytenoid impaction**. **Clinical Pearl:** This technique is especially valuable in awake fiberoptic intubation because: - The patient is conscious and can tolerate brief manipulation - The fiberscope provides real-time visualization of the obstruction - Gentle correction avoids the need for re-intubation ## Sequence of Actions for Arytenoid Impaction ```mermaid flowchart TD A[Tube catches at arytenoids during FOI]:::outcome B[Fiberscope still visible in lumen?]:::decision B -->|Yes| C[Rotate tube 90° counterclockwise]:::action C --> D[Advance gently]:::action D --> E{Tube advances?}:::decision E -->|Yes| F[Confirm position, secure tube]:::action E -->|No| G[Try rotation 90° clockwise]:::action G --> H{Success?}:::decision H -->|Yes| F H -->|No| I[Withdraw tube & scope, reassess]:::urgent I --> J[Consider smaller ETT or reattempt]:::action B -->|No| K[Withdraw immediately, reposition scope]:::urgent ``` **Mnemonic:** **ARYTENOID IMPACTION = ROTATE** — Remember: Rotation is the first rescue maneuver, not withdrawal. [cite:Ovassapian Fiberoptic Endoscopy & the Difficult Airway 2e Ch 5]