As the scope was inserted, there was no edema at the uvula or posterior oropharynx and no lesion. When progressed further, the scope passed the base of the tongue to expose a large lesion protruding into the airway with near-complete occlusion. The scope, pre-loaded with a small-caliber endotracheal tube, could not be passed around the lesion for intubation. The glottis and epiglottis could not be visualized. There were no signs of bleeding, but copious secretions made complete visualization of the lesion difficult. With a failed fiber-optic intubation, we prepared to perform an emergency surgical airway.

However, the patient continued to oxygenate and ventilate well. The lesion seen with the fiber-optic scope did not appear to be native tissue. It was gray, poorly circumscribed, and avascular. There was concern for a foreign body, though a large pseudomembrane, abscess, and laryngeal mass were also considered. With foreign body now as the leading diagnosis, the patient was kept upright and video laryngoscopy was employed to try and visualize the obstruction via a face-to-face or “tomahawk” approach.

It Wasn’t the Surf, It Was the Turf

After laryngoscope insertion, the lesion was clearly visualized. Magill forceps were quickly acquired to remove a large piece of masticated food. When removed, the food bolus was found to be directly superior to the epiglottis in the supraglottic region. The patient had immediate relief of symptoms and began speaking in a clear voice. Fiberoptic laryngoscopy was repeated, confirming no further foreign body, bleeding, or other pathology.

Figure 1: When removed, the food bolus was found to be directly superior to the epiglottis in the supraglottic region. (Click to enlarge.)

The patient was unaware of any aspiration and believed her symptoms were due to an allergic reaction to the seafood she was eating. After removal of the foreign body, she was asymptomatic, tolerating food and drink. She was observed for several hours with a chest X-ray showing no pulmonary edema or aspiration pneumonitis/pneumonia.

The Tomahawk Approach to Airway Management

Face-to-face intubation, commonly referred to as tomahawk or axe intubation, is a difficult airway intervention utilized in pre-hospital, emergency department, inpatient, and operating room settings.^2,3,4,5 Patients with pulmonary edema, significant spine pathology, obesity, etc. may not be able to tolerate laying supine.^4,6,8 This technique is valuable as it allows glottic visualization without placing patients in a supine position. As these patients are commonly seen in the emergency department, tomahawk intubation is an extremely useful technique to consider when dealing with a difficult airway.