Airway and positioning challenges in a patient with ankylosing spondylitis undergoing cholecystectomy: Role of intubating laryngeal mask airway and fiberoptic guidance
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Abstract
Ankylosing spondylitis (AS) produces progressive spinal rigidity, fixed deformity and restrictive lung disease, posing major challenges for airway management, positioning and ventilation. We report the anesthetic management of a 49‑year‑old man with severe AS, fixed cervicothoracic kyphosis, restrictive lung physiology and chronic voice change who presented for cholecystectomy. He could not lie supine and tolerated only a modified Fowler’s position. Anticipating a difficult airway and poor pulmonary reserve, an awake fiberoptic intubation was kept as backup, but we elected to perform asleep intubation through an intubating laryngeal mask airway (I‑LMA) because the patient was extremely anxious and unable to cooperate for a prolonged awake procedure in his compromised position. After meticulous padding and positioning, induction was achieved with titrated propofol and fentanyl while maintaining spontaneous breathing. An I‑LMA was inserted without neck movement, ventilation confirmed, and rocuronium administered. A 7.5‑mm endotracheal tube was then railroaded over a flexible fiberscope through the I‑LMA, which was subsequently removed. Laparoscopic cholecystectomy had to be converted to open surgery because pneumoperitoneum and instrument mobility were limited in the extreme semi‑recumbent posture. The intra‑operative and postoperative courses were uneventful; neuromuscular blockade was reversed with sugammadex and analgesia provided with multimodal opioids and non‑opioid agents. This case highlights the importance of individualized airway planning, careful positioning and the usefulness of I‑LMA–assisted fiberoptic intubation in AS patients with combined airway and positioning challenges. Keywords: Ankylosing spondylitis, Difficult airway, Intubating laryngeal mask airway, Fiberoptic intubation, Laparoscopic cholecystectomy, Restrictive lung disease.
Dates & metrics
- Received
- 12 Mar 2026
- Accepted
- 2 Jun 2026
- Published
- 11 Jun 2026
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References
1. Woodward LJ, Kam PC. Ankylosing spondylitis: recent developments and anaesthetic implications. Anaesthesia. 2009;64(5):540-8. https://doi.org/10.1111/j.1365-2044.2008.05794.x
2. Jiménez-Balderas FJ, Mintz G. Ankylosing spondylitis: clinical course in women and men. J Rheumatol. 1993;20(12):2069–72.
3. Kumar S, Doss RSA, Rebekah G, Mathews NS, Danda D, Mathew J et al. Prevalence of HLA-B*27 subtypes in the Tamil population of India with Ankylosing spondylitis and its correlation with clinical features. Hum Immunol. 2021;82(6):404–8. https://doi.org/10.1016/j.humimm.2021.03.001
4. Lee YK, Manek R, Hardman J, Ghedia R, Hariri A, Lacey O, et al. Transoral robotic surgery in a modified Trendelenburg position for oropharyngeal squamous cell carcinoma in a patient with severe thoracic kyphosis. Head Neck. 2023;45(3):E5–9. https://doi.org/10.1002/hed.27271
5. Ma LL, Yu XR, Zhu B, Huang YG, Shen JX, Zhang JG. Difficult Airway for Patients Undergoing Spine Surgeries. Chin Med J (Engl). 2016;129(6):749–50. https://doi.org/10.4103/0366-6999.178033
6. Mohanta J, Kumar A, Kaushal A, Talawar P, Gupta P, Jain G. Anaesthesia for Awake Fiberoptic Intubation: Ultrasound-Guided Airway Nerve Block versus Ultrasonic Nebulisation with Lignocaine. Discoveries (Craiova). 2021;9(1):e125. https://doi.org/10.15190/d.2021.4
7. Rebai L, Kalai F, Ardhaoui I, Brahem SB, Rabhi B, Fakhfakh H. Approaches to difficult airway management in a patient with ankylosing spondylitis and severe cervical spine deformities. Int J Surg Case Rep. 2025;130:111260. https://doi.org/10.1016/j.ijscr.2025.111260
8. Kumar N, Bindra A, Mahajan C, Yadav N. Airway management in a patient of ankylosing spondylitis with traumatic cervical spine injury. Saudi J Anaesth. 2015;9(3):327–9. https://doi.org/10.4103/1658-354X.154741
9. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022;136(1):31–81. https://doi.org/10.1097/ALN.0000000000004002
10. Gunaydin B, Gungor I, Yigit N, Celebi H. The Glidescope for tracheal intubation in patients with ankylosing spondylitis. Br J Anaesth. 2007;98(3):408–9. https://doi.org/10.1093/bja/ael384
11. Asthana V, Agrawal S, Singh DK, Sharma JP. Airway management in ankylosing spondylitis with intubating laryngeal mask airway – a case report. Indian Anaesth Forum. 2006;2(1):1–5.
12. Zhou Y, Zhang Y, Hu T, Li X, Fu Q. Anesthesia management of morbid obesity and ankylosing spondylitis with a difficult airway: a case report. Am J Transl Res. 2022;14(7):4860–3.
13. D'Mello J, Pagedar R, Butani M, Kurkal P, Pandey K. Use of the intubating laryngeal mask airway in a case of ankylosing spondylitis for coronary artery bypass grafting. Eur J Anaesthesiol. 2002;19(4):298–302. https://doi.org/10.1017/s0265021502000480
14. Raval C, Patel H, Patel P, Kharod U. Retrograde intubation in a case of ankylosing spondylitis posted for correction of deformity of spine. Saudi J Anaesth. 2010;4(1):38–41. https://doi.org/10.4103/1658-354X.62616
15. Kim BS, Joo SH, Joh JH, Yi JW. Laparoscopic cholecystectomy in patients with anesthetic problems. World J Gastroenterol. 2013;19(29):4832–5. https://doi.org/10.3748/wjg.v19.i29.4832
16. Son TQ, Hoc TH. Laparoscopic cholecystectomy for the treatment of acute cholecystitis in a Vietnamese male patient with ankylosing spondylitis combined with chronic obstructive pulmonary disease: A rare case report. Int J Surg Case Rep. 2022;90:106646. https://doi.org/10.1016/j.ijscr.2021.106646
17. Tu H. A Successful Endotracheal Intubation of a Patient with Ankylosing Spondylitis: A Case Report. Asploro Biomed Clin Case Rep. 2024;7(2):182–5. https://doi.org/10.36502/2024/ASJBCCR.6359
18. Hristovska AM, Duch P, Allingstrup M, Afshari A. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database Syst Rev. 2017;8(8):CD012763. https://doi.org/10.1002/14651858.CD012763
How to cite this article
Arora A, Rawat G, Koshiyari HS. Airway and positioning challenges in a patient with ankylosing spondylitis undergoing cholecystectomy: Role of intubating laryngeal mask airway and fiberoptic guidance. J. Sci. Innov. Anesthesiol. 2026;1(2):54-59. doi:10.65929/JSIA.2026.1.2.005
Arora, A., Rawat, G., & Koshiyari, H. S. (2026). Airway and positioning challenges in a patient with ankylosing spondylitis undergoing cholecystectomy: Role of intubating laryngeal mask airway and fiberoptic guidance. Journal of Scientific Innovations in Anesthesiology, 1(2), 54-59. https://doi.org/10.65929/JSIA.2026.1.2.005
Ankit Arora, Girish Rawat, and Harish Singh Koshiyari. "Airway and positioning challenges in a patient with ankylosing spondylitis undergoing cholecystectomy: Role of intubating laryngeal mask airway and fiberoptic guidance." Journal of Scientific Innovations in Anesthesiology, vol. 1, no. 2, 2026, pp. 54-59. https://doi.org/10.65929/JSIA.2026.1.2.005
Ankit Arora, Girish Rawat, and Harish Singh Koshiyari. "Airway and positioning challenges in a patient with ankylosing spondylitis undergoing cholecystectomy: Role of intubating laryngeal mask airway and fiberoptic guidance." Journal of Scientific Innovations in Anesthesiology 1, no. 2 (2026): 54-59. https://doi.org/10.65929/JSIA.2026.1.2.005
Arora, A., Rawat, G., and Koshiyari, H. S. (2026) 'Airway and positioning challenges in a patient with ankylosing spondylitis undergoing cholecystectomy: Role of intubating laryngeal mask airway and fiberoptic guidance', Journal of Scientific Innovations in Anesthesiology, 1(2), pp. 54-59. https://doi.org/10.65929/JSIA.2026.1.2.005
© 2026 the authors. Published by REVO Publication. This article is distributed under CC BY 4.0, which permits use and redistribution provided the original work is properly cited.