We provided a general anesthetic to a 35 year old male for surgical reduction of a displaced clavicular fracture. The patient’s history was significant for obesity and daily tobacco smoking. During preoperative assessment the patient was noted to have a hoarse voice; however, we were reassured by the patient’s report that his voice had been this way for “a very long time.” A previous anesthetic record was avalible and notable for two hand mask ventilation with an oral airway and grade 2B intubation view with direct laryngoscopy. His BMI had increased from 27 to 39 since the previous record.

We performed a standard induction which was initially notable for very difficult mask ventilation. We performed planned video laryngoscopy with a McGrath MAC #4 resulting in the following view:



Due to difficult mask ventilation we proceeded with intubation without fully investigating the mass. The mass was mobile posteriorly and we were able to easily pass a 6.0 ETT into the trachea:



Since the patient’s injury required urgent repair, we proceeded with the surgery without delay. We called for an intraoperative ENT consult. The ENT surgeon used a gum bougie to delineate the mass and determined that it was attached anteriorly and such masses are unlikely to compromise an airway acutely. Since extubation was likely safe, the ENT surgeon did not perform a biopsy or excision, so the patient could be properly consented for the procedure at a later date. We extubated the patient fully awake without complication.

In the PACU we questioned the patient again with family present. The patient’s wife immediately reported that she noticed a worsening of the patient’s usual hoarseness over the past 3 months.

The patient returned to the OR 1 week later for definitive diagnosis and excision of the mass. We induced the patient and intubated with a Karl Storz C-MAC S MAC #4 and 5.0 microlaryngoscopy ETT:

The mass was resected by the ENT surgeon and was shown to be a papilloma by pathology.