Combination of visual laryngoscope and bronchial occluder in a patient with subglottic stenosis undergoing lung cancer resection: A case report

Combination of visual laryngoscope and bronchial occluder in a patient with subglottic stenosis undergoing lung cancer resection: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Combination of visual laryngoscope and bronchial occluder in a patient with subglottic stenosis undergoing lung cancer resection: A case report Huiju Yang, Guangyan Zhang, Lidan Nong, Jieyuan Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6864035/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Nov, 2025 Read the published version in BMC Anesthesiology → Version 1 posted 11 You are reading this latest preprint version Abstract Purpose Subglottic stenosis (SGS) poses a unique airway management challenge for surgery patients requiring anesthesia. We present a case of SGS who successfully underwent lung cancer resection with the combination of a visual laryngeal mask and occluder for general anesthesia. We discuss the diagnosis and airway management for this rare and life-threatening condition. Case presentation A 67-year-old female patient was admitted to the hospital due to pulmonary nodules for more than one month. The patient had a history of thoracoscopic resection of posterior mediastinal tumor under general anesthesia. The computed tomography (CT) revealed multiple solid nodules in the medial segment of the right middle lobe, suggesting peripheral lung cancer. The patient was initially arranged for lung cancer resection under general anesthesia with bronchial intubation. After three failed attempts for bronchial intubation, we found a moderate stenosis of the airway 1 cm below the glottis, confirming SGS. We then used a bronchial occluder combined with a visual laryngeal mask for general anesthesia and successfully performed the lung cancer resection. After surgery, the patient recovered well and was subsequently discharged from the hospital. Conclusion Clinicians should consider the possibility of SGS for patients with a history of intubation. The combined use of a bronchial occluder and visual laryngeal mask presents a novel, effective strategy for airway management in this patient. More studies are needed to validate the clinical safety and utility of this method further in the future. Subglottic stenosis (SGS) visual laryngeal mask bronchial occlude lung cancer resection anesthesia Figures Figure 1 Figure 2 Introduction Subglottic stenosis (SGS) is a rare but life-threatening condition characterized by the narrowing or atresia of the laryngeal cavity caused by laryngeal scar tissue [ 1 ]. Multiple factors can cause SGS, including congenital factors, infectious laryngitis or tracheitis, autoimmune conditions, laryngeal trauma, laryngeal surgery, postintubation injury, and tracheal tumor, with intubation- or tracheostomy-related trauma being the most common causes [ 2 ]. Although the prevalence of SGS in the general population remains unknown, the incidence of postintubation SGS is estimated to be 4.9 cases per million person-years, among which 30% are idiopathic SGS [ 3 , 4 ]. SGS mainly affects middle-aged females, with few cases in males [ 4 , 5 ]. SGS may present no symptoms in the early stages but may show acute respiratory distress in later advanced stages [ 1 , 2 ]. In the surgery setting, SGS poses a significant challenge for airway management under anesthesia. Patients with SGS have a high risk of intubation failure since it is difficult for a double-lumen endotracheal tube to pass through the stenosis. We presented a case of SGS who initially failed intubation and then successfully underwent lung cancer resection with the combination of a visual laryngeal mask and bronchial occluder for general anesthesia. We discussed the diagnosis and airway management of SGS. Case presentation This work was A 67-year-old female patient (height:152cm; weight: 59kg) was admitted to the hospital with the main complaint of pulmonary nodules found during a physical examination over one month ago. She had a history of diabetes and took oral hypoglycemic drugs to control his blood sugar. She reported that her blood sugar was under control. In 2012, she underwent thoracoscopic resection of a posterior mediastinal tumor under general anesthesia. In the past three years, she had shortness of breath after activity, which was not treated. She denied any history of allergies.Her electrocardiogram and cardiac color Doppler ultrasound were normal. Blood tests showed no obvious abnormalities. The computed tomography (CT) revealed multiple solid nodules in the medial segment of the right middle lobe, with the largest one measured at 18 mmx10 mm, suggesting peripheral lung cancer. Her final diagnoses were lung mass (right middle lobe nodule, lung cancer, cT1bN0M0 IA2) and type 2 diabetes. The patient was initially arranged for lung cancer resection under general anesthesia with bronchial intubation. Preoperative airway assessment showed that the patient was in good general condition, with good mobility of the head and neck. According to the Mallampati classification, the patient was at Grade II, suggesting a relatively easy laryngoscopy with a low to moderate likelihood of airway management difficulty during anesthesia. The patient had comorbid diabetes with well-controlled blood sugar. The patient had American Society of Anesthesiologists (ASA) grade II, cardiac function grade I, and normal lung function. The surgery was planned to be performed under general anesthesia with bronchial intubation, and a No. 35 left double-lumen tube was used for lung isolation. After the patient entered the operating room, we monitored her vital signs, induced rapid anesthesia, and performed mask ventilation. After the general anesthesia took effect, a 35 Fr left bronchial tube was intubated under a visual laryngoscope. The blue cuff of the endotracheal tube could not be inserted into the airway after passing through the glottis. Intubation was attempted again, but the endotracheal tube still could not pass. Methylprednisolone 40mg was given to prevent airway edema, mask ventilation was continued, and another intubation attempt was made using a 32Fr left catheter. However, the endotracheal tube still could not be inserted into the airway. Considering that three tracheal intubation attempts had been made, we immediately inserted a 5.5 single-lumen tube to prevent the potential ventilation failure caused by airway edema and suspended the operation. The patient was sent to the recovery room and returned to the ward after regaining consciousness. The patient further underwent bronchoscopy for airway examination, and a moderate stenosis of the airway was found 1 cm below the glottis, confirming SGS. A fiberoptic bronchoscope with an outer diameter of 5.3cm could pass through the stenosis. One week later, the patient returned to the operating room for lung cancer resection again. Considering the patient's SGS, we used a visual laryngeal mask combined with a bronchial occluder for lung isolation. After the patient entered the room for vital signs monitoring, we assembled the 9F bronchial occluder to the safeLM 4# visual laryngeal mask intubation port in advance. Anesthesia was induced intravenously with propofol (100 mg), sufentanil (20), and atracurium besylate (15 mg). Once the patient's muscles were relaxed, a visual laryngoscope was used to expose the glottis, and a 9F bronchial occluder was first inserted into the glottis and then into the visual laryngeal mask connected to the ventilation machine (Fig. 1 . A, B). The bronchial occluder was gradually adjusted, guided by a fibro bronchoscope, to make sure the cuff entered the right main bronchus. During the operation, the patient's vital signs were stable, airway ventilation was good, and the degree of lung collapse was satisfactory (Fig. 2). The patient underwent a thoracoscopic right middle lobectomy and thoracic lymph node biopsy. The operation lasted 150 minutes. After the operation, the occluder was removed. The patient woke up 30 minutes after being sent to the recovery room, and the laryngeal mask was removed. The patient was observed in the anesthesia recovery room for 30 minutes and returned to the ward after she was fully awake. She had only mild postoperative wound pain, no sore throat, no nausea, and no vomiting. The chest tube was removed on the third day after surgery, and the chest X-ray showed good lung recruitment. The patient was discharged successfully on the third postoperative day. No anesthesia complications were found. Discussion SGS poses a significant challenge for airway management for patients undergoing surgery under general anesthesia. Patients with a history of intubation and symptoms of breathing difficulty may indicate SGS and thus warrant special clinical attention. Before the surgery, it is crucial to comprehensively review the patient's medical history, assess their symptoms and signs, and evaluate the perioperative risk factors. During the surgery, vigilant intraoperative anesthetic monitoring is essential to identify any risks and take immediate action to adjust the airway management plan. After the surgery, a thorough assessment and preparation should be made to ensure safe extubating and rapid recovery of the patients. In this study, we presented a case of SGS who initially failed intubation and then successfully underwent lung cancer resection with the combination of a visual laryngeal mask and bronchial occluder for general anesthesia. Patients with SGS have a high risk of intubation failure during double-lumen endotracheal intubation. This patient had a history of diabetes and mediastinal surgery under general anesthesia with intubation, which may contribute to the development of postintubation SGS. The visual laryngeal mask combined with the bronchial occluder successfully passed through the stenosis, making the alignment of the laryngeal mask visible during the operation, which enabled the patient to achieve one-lung ventilation in the lateral decubitus position successfully. The laryngeal mask is the most commonly used supraglottic airway tool [ 6 ]. It is inserted into the throat and inflated to form a sealing ring around the throat. As a ventilation tool between the endotracheal tube and the mask, it can support spontaneous breathing and positive pressure ventilation. In clinical practice, it has been widely used for airway management in various conditions, including routine surgical ventilation, difficult ventilation, emergency ventilation, and ventilation for critically ill patients. First developed by British doctor Brain based on the structure of the human throat [ 7 ], the laryngeal masks have now evolved into the following types: ordinary laryngeal masks, flexible laryngeal masks, intubation laryngeal masks, and visual laryngeal masks [ 8 ]. The models and functions of laryngeal masks are constantly updated during development, and they have been proven to be safe and effective in some difficult airways [ 9 ]. A study retrospectively evaluated the use of laryngeal mask ventilation in tracheal surgeries of 21 pediatric and adult patients with various conditions. The results showed that laryngeal mask ventilation was safe and effective in the surgery of benign and malignant diseases of both the upper and lower airway [ 10 ]. In this case, we used the safe LM disposable visual laryngeal mask with an adjustable viewing angle produced by Changsha McGill Medical Co., Ltd. Its major characteristic is that the entire laryngeal mask insertion process is visible, which can guide the operator to accurately and efficiently insert the laryngeal mask. This process can reduce damage and irritation to the epiglottis, larynx, and surrounding tissues during laryngeal mask insertion, as well as prevent foreign objects from accidentally entering the airway. As a new generation of laryngeal mask tools, the visual laryngeal mask can provide a direct vision of the epiglottis and the position of the laryngeal mask to avoid displacement and compression of the epiglottis [ 11 ]. A study applied a SaCoVLMTM visual laryngeal mask to three morbidly obese patients when they were awake, and the entire anesthesia induction and intubation process was visible. There was no adverse event and no unpleasant recall from the patients, indicating its safety and feasibility for awake orotracheal intubation [ 12 ]. A laryngeal mask combined with a bronchial occluder can achieve one-lung ventilation, which has been confirmed in esophageal cancer and lung cancer surgeries. A study compared the application of laryngeal mask combined with occluder (LMCO) and tube intubation combined with occluder (TICO) in thoracic surgery. It showed no significant difference in the positioning time of the tracheal occluder and the degree of lung collapse between the TICO and LMCO groups. However, the LMCO group had lower mean arterial pressure, heart rate, and cortisol immediately after intubation [ 13 ]. A study on minimally invasive thoracic surgery using a visual laryngeal mask combined with an occluder showed that the laryngeal mask group used less vasoactive drugs after intubation, woke up faster, and had a lower incidence of sore throat than the endotracheal intubation group. This shows that the laryngeal mask combined with occluder is safe and effective in minimally invasive thoracoscopic surgery [ 14 ]. In this case, the patient had SGS, rendering the double-lumen endotracheal tube and large-sized endotracheal tube not able to pass through the stenosis. The airway could not be established by conventional double-lumen endotracheal intubation or endotracheal intubation with an occluder. After the use of a visual laryngeal mask to establish supraglottic ventilation, the occluder smoothly passed through the stenosis and achieved lung isolation. A main advantage of the visual laryngeal mask is that the position of the laryngeal mask can be observed and adjusted in time to avoid displacement during chest surgery in the lateral position. The patient said she was satisfied with the surgery and analgesic effect. Conclusion In summary, the video laryngeal mask combined with the bronchial occluder can effectively achieve lung isolation and can be used to establish one-lung ventilation for patients with difficult airways such as SGS. More clinical studies are needed to test the effectiveness of this novel approach in optimizing airway management across diverse clinical settings in the future. Abbreviations SGS Subglottic stenosis CT computed tomography Declarations Ethics approval and consent to participate Not applicable Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Funding This work was supported by the grant (NO. KY012021698) of inner hospital funding of Guangdong Provincial People's Hospital. Author Contribution Huiju Yang drafted the manuscript. Lidan Nong was in charge of the patient’s anesthetic management. Guangyan Zhang edited the figures. Jieyuan Chen revised the manuscript. All authors read and approved the final manuscript. Acknowledgement We thank the patient for her consent to publish this report. Availability of data and materials No datasets were generated or analysed during the current study. Competing interests The authors declare no competing interests. References Stephenson KA, Wyatt ME. Glottic stenosis. In Seminars in pediatric surgery 2016 Jun 1 (Vol. 25, No. 3, pp. 132–7). WB Saunders. Bell RK, Lentz SA, Patten JC, Atchinson PRA, Roginski MA. Airway and Ventilator Management in a New Presentation of Idiopathic Subglottic Stenosis: A Case Report. Air Med J. 2024;43(5):450–3. Nouraei SAR, Ma E, Patel A, Howard DJ, Sandhu GS. Estimating the population incidence of adult post-intubation laryngotracheal stenosis. Clinical otolaryngology: official journal of ENT-UK; official journal of Netherlands Society for Oto-Rhino-Laryngology. Cervico-Facial Surg. 2007;32(5):411–2. Maldonado F, Loiselle A, DePew ZS, Edell ES, Ekbom DC, Malinchoc M, Hagen CE, Alon E, Kasperbauer JL. Idiopathic subglottic stenosis: an evolving therapeutic algorithm. Laryngoscope. 2014;124(2):498–503. Poetker DM, Ettema SL, Blumin JH, Toohill RJ, Merati AL. Association of airway abnormalities and risk factors in 37 subglottic stenosis patients. Otolaryngology—Head and Neck Surgery. 2006;135(3):434-7. [2] SIOMON LV, TORP KD. Laryngeal Mask Airway. 2023 Jul 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. Torp 6SLV. KD. Laryngeal mask airway. InStatPearls [Internet] 2023 Jul 11. StatPearls Publishing. Van Zundert TC, Brimacombe JR, Ferson DZ, Bacon DR, Wilkinson DJ. Archie Brain: celebrating 30 years of development in laryngeal mask airways. Anaesthesia. 2012;67(12):1375–85. Chen C, Tang J. New progress in the selection of types and models of laryngeal masks [J]. Yanbian Med. 2015;000(007):81–4. Madhivathanan 9KLE. Supraglottic airway devices: current and future uses. Br J Hosp Med. 2018;79(1):31–5. Celik A, Sayan M, Kankoc A, Tombul I, Kurul IC, Tastepe AI. Various uses of laryngeal mask airway during tracheal surgery. The Thoracic and cardiovascular surgeon. 2021 Mar 19:764–8. Yan CL, Zhang YQ, Chen Y, Qv ZY, Zuo MZ. Comparison of SaCoVLM™ video laryngeal mask-guided intubation and i-gel combined with flexible bronchoscopy-guided intubation in airway management during general anesthesia: a non-inferiority study. BMC Anesthesiol. 2022;22(1):302. Sun Y, Huang L, Xu L, Zhang M, Guo Y, Wang Y. The application of a SaCoVLMTM visual intubation laryngeal mask for the management of difficult airways in morbidly obese patients: case report. Front Med. 2021;8:763103. Wang W, Zhang C, Gao H, et al. Clinical application of laryngeal mask combined with bronchial occluder in general anesthesia in thoracoscopic one-lung ventilation [J]. Chin Contemp Med. 2019;26(9):4. He D, Feng J, Yang Y, et al. Application of laryngeal mask combined with bronchial occluder in general anesthesia for thoracoscopic one-lung ventilation [J]. J Clin Anesth. 2015;31(11):2. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 29 Nov, 2025 Read the published version in BMC Anesthesiology → Version 1 posted Editorial decision: Revision requested 17 Aug, 2025 Reviews received at journal 23 Jul, 2025 Reviewers agreed at journal 23 Jul, 2025 Reviews received at journal 21 Jul, 2025 Reviewers agreed at journal 21 Jul, 2025 Reviewers agreed at journal 14 Jul, 2025 Reviewers invited by journal 14 Jul, 2025 Editor invited by journal 17 Jun, 2025 Editor assigned by journal 17 Jun, 2025 Submission checks completed at journal 17 Jun, 2025 First submitted to journal 10 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6864035","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":485300625,"identity":"aa77d210-ad0c-4742-9a67-4b6863ab9814","order_by":0,"name":"Huiju Yang","email":"","orcid":"","institution":"Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Huiju","middleName":"","lastName":"Yang","suffix":""},{"id":485300626,"identity":"3e40e172-0efc-43dd-b3ff-72ce6dc425bd","order_by":1,"name":"Guangyan Zhang","email":"","orcid":"","institution":"Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Guangyan","middleName":"","lastName":"Zhang","suffix":""},{"id":485300627,"identity":"3c3f9c78-bd39-43a2-92f4-b16137ea847b","order_by":2,"name":"Lidan Nong","email":"","orcid":"","institution":"Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Lidan","middleName":"","lastName":"Nong","suffix":""},{"id":485300628,"identity":"a2d1d162-d5b8-4e45-9b69-5b6238451e80","order_by":3,"name":"Jieyuan Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYDACCRA2ADMZHzCwMSSQpIXZgHgtUMAmQZQW/tnNxx5YFNgkbjh+9ljll7I7eQzsvY9fMNTcwW3JnWPpBhIGaYkbzuSl3ZY596yYgee4mQXDsWc4tRhI5JhJSBgcTtxwIMfstmTb4cQGiTQ2A8aGw3i05H8DavmfuOH8G7NiIrXksAG1HEjccCPHjPEjRAvzA3xaJG6kgRyWbDzzxhtjaYZzzxLbeI4Bw+0Ybi38M5KfSUv8sZPtO59j+PFH2Z3EfvY25g8fanBrAQFmYNw4NoAYPAwHgFEDjKAEvBqACeUDA4M9mPEDqAWk9QMBHaNgFIyCUTCyAABEYVlY2HplLAAAAABJRU5ErkJggg==","orcid":"","institution":"Guangdong Academy of Medical Sciences, Southern Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jieyuan","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2025-06-10 14:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6864035/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6864035/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12871-025-03499-9","type":"published","date":"2025-11-29T15:56:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87040047,"identity":"e6bcd998-fa14-46ee-befe-2b9e6384e9f6","added_by":"auto","created_at":"2025-07-18 13:42:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":467779,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6864035/v1/339917fe4ce7453a2753f558.png"},{"id":87038134,"identity":"28120045-b6b8-414f-adf6-c83f8a5b93ba","added_by":"auto","created_at":"2025-07-18 13:26:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":564768,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6864035/v1/475b0d9947fc42572c351a69.png"},{"id":97178400,"identity":"99da318f-2e59-4273-b3ff-3cab7bbe0951","added_by":"auto","created_at":"2025-12-01 16:09:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2752764,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6864035/v1/0a9777d3-18aa-4f8c-a48d-e70eff67ea2b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Combination of visual laryngoscope and bronchial occluder in a patient with subglottic stenosis undergoing lung cancer resection: A case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSubglottic stenosis (SGS) is a rare but life-threatening condition characterized by the narrowing or atresia of the laryngeal cavity caused by laryngeal scar tissue [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Multiple factors can cause SGS, including congenital factors, infectious laryngitis or tracheitis, autoimmune conditions, laryngeal trauma, laryngeal surgery, postintubation injury, and tracheal tumor, with intubation- or tracheostomy-related trauma being the most common causes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although the prevalence of SGS in the general population remains unknown, the incidence of postintubation SGS is estimated to be 4.9 cases per million person-years, among which 30% are idiopathic SGS [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. SGS mainly affects middle-aged females, with few cases in males [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. SGS may present no symptoms in the early stages but may show acute respiratory distress in later advanced stages [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the surgery setting, SGS poses a significant challenge for airway management under anesthesia. Patients with SGS have a high risk of intubation failure since it is difficult for a double-lumen endotracheal tube to pass through the stenosis. We presented a case of SGS who initially failed intubation and then successfully underwent lung cancer resection with the combination of a visual laryngeal mask and bronchial occluder for general anesthesia. We discussed the diagnosis and airway management of SGS.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThis work was A 67-year-old female patient (height:152cm; weight: 59kg) was admitted to the hospital with the main complaint of pulmonary nodules found during a physical examination over one month ago. She had a history of diabetes and took oral hypoglycemic drugs to control his blood sugar. She reported that her blood sugar was under control. In 2012, she underwent thoracoscopic resection of a posterior mediastinal tumor under general anesthesia. In the past three years, she had shortness of breath after activity, which was not treated. She denied any history of allergies.Her electrocardiogram and cardiac color Doppler ultrasound were normal. Blood tests showed no obvious abnormalities. The computed tomography (CT) revealed multiple solid nodules in the medial segment of the right middle lobe, with the largest one measured at 18 mmx10 mm, suggesting peripheral lung cancer. Her final diagnoses were lung mass (right middle lobe nodule, lung cancer, cT1bN0M0 IA2) and type 2 diabetes.\u003c/p\u003e\u003cp\u003eThe patient was initially arranged for lung cancer resection under general anesthesia with bronchial intubation. Preoperative airway assessment showed that the patient was in good general condition, with good mobility of the head and neck. According to the Mallampati classification, the patient was at Grade II, suggesting a relatively easy laryngoscopy with a low to moderate likelihood of airway management difficulty during anesthesia. The patient had comorbid diabetes with well-controlled blood sugar. The patient had American Society of Anesthesiologists (ASA) grade II, cardiac function grade I, and normal lung function. The surgery was planned to be performed under general anesthesia with bronchial intubation, and a No. 35 left double-lumen tube was used for lung isolation.\u003c/p\u003e\u003cp\u003eAfter the patient entered the operating room, we monitored her vital signs, induced rapid anesthesia, and performed mask ventilation. After the general anesthesia took effect, a 35 Fr left bronchial tube was intubated under a visual laryngoscope. The blue cuff of the endotracheal tube could not be inserted into the airway after passing through the glottis. Intubation was attempted again, but the endotracheal tube still could not pass. Methylprednisolone 40mg was given to prevent airway edema, mask ventilation was continued, and another intubation attempt was made using a 32Fr left catheter. However, the endotracheal tube still could not be inserted into the airway. Considering that three tracheal intubation attempts had been made, we immediately inserted a 5.5 single-lumen tube to prevent the potential ventilation failure caused by airway edema and suspended the operation. The patient was sent to the recovery room and returned to the ward after regaining consciousness. The patient further underwent bronchoscopy for airway examination, and a moderate stenosis of the airway was found 1 cm below the glottis, confirming SGS. A fiberoptic bronchoscope with an outer diameter of 5.3cm could pass through the stenosis.\u003c/p\u003e\u003cp\u003eOne week later, the patient returned to the operating room for lung cancer resection again. Considering the patient's SGS, we used a visual laryngeal mask combined with a bronchial occluder for lung isolation. After the patient entered the room for vital signs monitoring, we assembled the 9F bronchial occluder to the safeLM 4# visual laryngeal mask intubation port in advance. Anesthesia was induced intravenously with propofol (100 mg), sufentanil (20), and atracurium besylate (15 mg). Once the patient's muscles were relaxed, a visual laryngoscope was used to expose the glottis, and a 9F bronchial occluder was first inserted into the glottis and then into the visual laryngeal mask connected to the ventilation machine (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A, B). The bronchial occluder was gradually adjusted, guided by a fibro bronchoscope, to make sure the cuff entered the right main bronchus. During the operation, the patient's vital signs were stable, airway ventilation was good, and the degree of lung collapse was satisfactory (Fig.\u0026nbsp;2). The patient underwent a thoracoscopic right middle lobectomy and thoracic lymph node biopsy. The operation lasted 150 minutes.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAfter the operation, the occluder was removed. The patient woke up 30 minutes after being sent to the recovery room, and the laryngeal mask was removed. The patient was observed in the anesthesia recovery room for 30 minutes and returned to the ward after she was fully awake. She had only mild postoperative wound pain, no sore throat, no nausea, and no vomiting. The chest tube was removed on the third day after surgery, and the chest X-ray showed good lung recruitment. The patient was discharged successfully on the third postoperative day. No anesthesia complications were found.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSGS poses a significant challenge for airway management for patients undergoing surgery under general anesthesia. Patients with a history of intubation and symptoms of breathing difficulty may indicate SGS and thus warrant special clinical attention. Before the surgery, it is crucial to comprehensively review the patient's medical history, assess their symptoms and signs, and evaluate the perioperative risk factors. During the surgery, vigilant intraoperative anesthetic monitoring is essential to identify any risks and take immediate action to adjust the airway management plan. After the surgery, a thorough assessment and preparation should be made to ensure safe extubating and rapid recovery of the patients. In this study, we presented a case of SGS who initially failed intubation and then successfully underwent lung cancer resection with the combination of a visual laryngeal mask and bronchial occluder for general anesthesia.\u003c/p\u003e\u003cp\u003ePatients with SGS have a high risk of intubation failure during double-lumen endotracheal intubation. This patient had a history of diabetes and mediastinal surgery under general anesthesia with intubation, which may contribute to the development of postintubation SGS. The visual laryngeal mask combined with the bronchial occluder successfully passed through the stenosis, making the alignment of the laryngeal mask visible during the operation, which enabled the patient to achieve one-lung ventilation in the lateral decubitus position successfully.\u003c/p\u003e\u003cp\u003eThe laryngeal mask is the most commonly used supraglottic airway tool [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. It is inserted into the throat and inflated to form a sealing ring around the throat. As a ventilation tool between the endotracheal tube and the mask, it can support spontaneous breathing and positive pressure ventilation. In clinical practice, it has been widely used for airway management in various conditions, including routine surgical ventilation, difficult ventilation, emergency ventilation, and ventilation for critically ill patients. First developed by British doctor Brain based on the structure of the human throat [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], the laryngeal masks have now evolved into the following types: ordinary laryngeal masks, flexible laryngeal masks, intubation laryngeal masks, and visual laryngeal masks [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The models and functions of laryngeal masks are constantly updated during development, and they have been proven to be safe and effective in some difficult airways [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A study retrospectively evaluated the use of laryngeal mask ventilation in tracheal surgeries of 21 pediatric and adult patients with various conditions. The results showed that laryngeal mask ventilation was safe and effective in the surgery of benign and malignant diseases of both the upper and lower airway [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this case, we used the safe LM disposable visual laryngeal mask with an adjustable viewing angle produced by Changsha McGill Medical Co., Ltd. Its major characteristic is that the entire laryngeal mask insertion process is visible, which can guide the operator to accurately and efficiently insert the laryngeal mask. This process can reduce damage and irritation to the epiglottis, larynx, and surrounding tissues during laryngeal mask insertion, as well as prevent foreign objects from accidentally entering the airway. As a new generation of laryngeal mask tools, the visual laryngeal mask can provide a direct vision of the epiglottis and the position of the laryngeal mask to avoid displacement and compression of the epiglottis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A study applied a SaCoVLMTM visual laryngeal mask to three morbidly obese patients when they were awake, and the entire anesthesia induction and intubation process was visible. There was no adverse event and no unpleasant recall from the patients, indicating its safety and feasibility for awake orotracheal intubation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA laryngeal mask combined with a bronchial occluder can achieve one-lung ventilation, which has been confirmed in esophageal cancer and lung cancer surgeries. A study compared the application of laryngeal mask combined with occluder (LMCO) and tube intubation combined with occluder (TICO) in thoracic surgery. It showed no significant difference in the positioning time of the tracheal occluder and the degree of lung collapse between the TICO and LMCO groups. However, the LMCO group had lower mean arterial pressure, heart rate, and cortisol immediately after intubation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A study on minimally invasive thoracic surgery using a visual laryngeal mask combined with an occluder showed that the laryngeal mask group used less vasoactive drugs after intubation, woke up faster, and had a lower incidence of sore throat than the endotracheal intubation group. This shows that the laryngeal mask combined with occluder is safe and effective in minimally invasive thoracoscopic surgery [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this case, the patient had SGS, rendering the double-lumen endotracheal tube and large-sized endotracheal tube not able to pass through the stenosis. The airway could not be established by conventional double-lumen endotracheal intubation or endotracheal intubation with an occluder. After the use of a visual laryngeal mask to establish supraglottic ventilation, the occluder smoothly passed through the stenosis and achieved lung isolation. A main advantage of the visual laryngeal mask is that the position of the laryngeal mask can be observed and adjusted in time to avoid displacement during chest surgery in the lateral position. The patient said she was satisfied with the surgery and analgesic effect.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, the video laryngeal mask combined with the bronchial occluder can effectively achieve lung isolation and can be used to establish one-lung ventilation for patients with difficult airways such as SGS. More clinical studies are needed to test the effectiveness of this novel approach in optimizing airway management across diverse clinical settings in the future.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSGS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSubglottic stenosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecomputed tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis work was supported by the grant (NO. KY012021698) of inner hospital funding of Guangdong Provincial People's Hospital.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eHuiju Yang drafted the manuscript. Lidan Nong was in charge of the patient\u0026rsquo;s anesthetic management. Guangyan Zhang edited the figures. Jieyuan Chen revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eWe thank the patient for her consent to publish this report.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cb\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStephenson KA, Wyatt ME. Glottic stenosis. In Seminars in pediatric surgery 2016 Jun 1 (Vol. 25, No. 3, pp. 132\u0026ndash;7). WB Saunders.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBell RK, Lentz SA, Patten JC, Atchinson PRA, Roginski MA. Airway and Ventilator Management in a New Presentation of Idiopathic Subglottic Stenosis: A Case Report. Air Med J. 2024;43(5):450\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNouraei SAR, Ma E, Patel A, Howard DJ, Sandhu GS. Estimating the population incidence of adult post-intubation laryngotracheal stenosis. Clinical otolaryngology: official journal of ENT-UK; official journal of Netherlands Society for Oto-Rhino-Laryngology. Cervico-Facial Surg. 2007;32(5):411\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaldonado F, Loiselle A, DePew ZS, Edell ES, Ekbom DC, Malinchoc M, Hagen CE, Alon E, Kasperbauer JL. Idiopathic subglottic stenosis: an evolving therapeutic algorithm. Laryngoscope. 2014;124(2):498\u0026ndash;503.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePoetker DM, Ettema SL, Blumin JH, Toohill RJ, Merati AL. Association of airway abnormalities and risk factors in 37 subglottic stenosis patients. Otolaryngology\u0026mdash;Head and Neck Surgery. 2006;135(3):434-7. [2] SIOMON LV, TORP KD. Laryngeal Mask Airway. 2023 Jul 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan\u0026amp;#8211.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTorp 6SLV. KD. Laryngeal mask airway. InStatPearls [Internet] 2023 Jul 11. StatPearls Publishing.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan Zundert TC, Brimacombe JR, Ferson DZ, Bacon DR, Wilkinson DJ. Archie Brain: celebrating 30 years of development in laryngeal mask airways. Anaesthesia. 2012;67(12):1375\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen C, Tang J. New progress in the selection of types and models of laryngeal masks [J]. Yanbian Med. 2015;000(007):81\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMadhivathanan 9KLE. Supraglottic airway devices: current and future uses. Br J Hosp Med. 2018;79(1):31\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCelik A, Sayan M, Kankoc A, Tombul I, Kurul IC, Tastepe AI. Various uses of laryngeal mask airway during tracheal surgery. The Thoracic and cardiovascular surgeon. 2021 Mar 19:764\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYan CL, Zhang YQ, Chen Y, Qv ZY, Zuo MZ. Comparison of SaCoVLM\u0026trade; video laryngeal mask-guided intubation and i-gel combined with flexible bronchoscopy-guided intubation in airway management during general anesthesia: a non-inferiority study. BMC Anesthesiol. 2022;22(1):302.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSun Y, Huang L, Xu L, Zhang M, Guo Y, Wang Y. The application of a SaCoVLMTM visual intubation laryngeal mask for the management of difficult airways in morbidly obese patients: case report. Front Med. 2021;8:763103.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang W, Zhang C, Gao H, et al. Clinical application of laryngeal mask combined with bronchial occluder in general anesthesia in thoracoscopic one-lung ventilation [J]. Chin Contemp Med. 2019;26(9):4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHe D, Feng J, Yang Y, et al. Application of laryngeal mask combined with bronchial occluder in general anesthesia for thoracoscopic one-lung ventilation [J]. J Clin Anesth. 2015;31(11):2.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Subglottic stenosis (SGS), visual laryngeal mask, bronchial occlude, lung cancer resection, anesthesia","lastPublishedDoi":"10.21203/rs.3.rs-6864035/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6864035/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSubglottic stenosis (SGS) poses a unique airway management challenge for surgery patients requiring anesthesia. We present a case of SGS who successfully underwent lung cancer resection with the combination of a visual laryngeal mask and occluder for general anesthesia. We discuss the diagnosis and airway management for this rare and life-threatening condition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 67-year-old female patient was admitted to the hospital due to pulmonary nodules for more than one month. The patient had a history of thoracoscopic resection of posterior mediastinal tumor under general anesthesia. The computed tomography (CT) revealed multiple solid nodules in the medial segment of the right middle lobe, suggesting peripheral lung cancer. The patient was initially arranged for lung cancer resection under general anesthesia with bronchial intubation. After three failed attempts for bronchial intubation, we found a moderate stenosis of the airway 1 cm below the glottis, confirming SGS. We then used a bronchial occluder combined with a visual laryngeal mask for general anesthesia and successfully performed the lung cancer resection. After surgery, the patient recovered well and was subsequently discharged from the hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinicians should consider the possibility of SGS for patients with a history of intubation. The combined use of a bronchial occluder and visual laryngeal mask presents a novel, effective strategy for airway management in this patient. More studies are needed to validate the clinical safety and utility of this method further in the future.\u003c/p\u003e","manuscriptTitle":"Combination of visual laryngoscope and bronchial occluder in a patient with subglottic stenosis undergoing lung cancer resection: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 13:26:17","doi":"10.21203/rs.3.rs-6864035/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-18T01:39:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-23T14:41:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289312527363456735254050197335942255906","date":"2025-07-23T07:47:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-21T09:43:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"263900288770382196431304773355463271709","date":"2025-07-21T08:14:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121704730291502098711972372574372973235","date":"2025-07-14T13:06:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-14T12:58:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-17T05:10:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-17T04:47:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-17T04:47:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2025-06-10T14:09:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f213f436-5511-4925-bf11-b57364a80ac0","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:02:18+00:00","versionOfRecord":{"articleIdentity":"rs-6864035","link":"https://doi.org/10.1186/s12871-025-03499-9","journal":{"identity":"bmc-anesthesiology","isVorOnly":false,"title":"BMC Anesthesiology"},"publishedOn":"2025-11-29 15:56:57","publishedOnDateReadable":"November 29th, 2025"},"versionCreatedAt":"2025-07-18 13:26:17","video":"","vorDoi":"10.1186/s12871-025-03499-9","vorDoiUrl":"https://doi.org/10.1186/s12871-025-03499-9","workflowStages":[]},"version":"v1","identity":"rs-6864035","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6864035","identity":"rs-6864035","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}