[A case report: perioperative management of adenotonsillectomy in a morbidly obese patient with severe obstructive sleep apnea syndrome].

A male patient in his thirties was scheduled to undergo adenotonsillectomy due to dyspnea from bilateral tonsillar hypertrophy. He was morbidly obese (body mass index 56 kg x m(-2)) with severe obstructive sleep apnea syndrome (OSAS), and thus was evaluated with extreme risk for difficult ventilation and intubation. We planned awake intubation via video-assisted laryngoscopy and fiberoptic bronchoscopy under dexmedetomidine sedation, and the intubation was successfully performed. After adenotonsillectomy, upper airway obstruction due to hemorrhage and oropharyngeal swelling can be life-threatening requiring emergent airway management. Thus for postoperative airway management, due to the possibility of "cannot intubate, cannot ventilate" (CICV) and presumed difficult tracheotomy, we scheduled to perform tracheotomy during adenotonsillectomy, right after anesthetic induction and awake intubation. On postoperative day 1, he started walking with no need of sedative drugs. On day 4, after confirmation of minimal oropharyngeal swelling, tracheal cannulae was removed, and no further complications were observed in his postoperative course. We conclude that careful preoperative evaluation of the airway, retention of spontaneous breathing via awake intubation, and preventive tracheotomy for postoperative airway management are important points in perioperative management of a morbidly obese patient with severe obstructive sleep apnea syndrome.