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      Anesthetic management of difficult airway in a patient with massive neurofibroma of face: Utility of Rendell Baker Soucek mask and left molar approach for ventilation and intubation

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          Abstract

          Dear Editor, Mask ventilation is an essential skill in airway management, and loss of control of mask ventilation can create a situation from can ventilate, can’t intubate to a situation of can’t ventilate, can’t intubate. We wish to describe the utility of Rendell Baker Soucek mask and left molar approach for mask ventilation and tracheal intubation in a patient of massive neurofibroma of face scheduled for debulking of the mass. A 45 kg, 28-year-old woman was scheduled for debulking of a neurofibroma occupying almost the entire right half of the face. This lesion, involving right nasal alae and right eyelid, was present since 20 years, was painless, and had progressed to size shown in. The patient could not see with her right eye. There was no other positive medical history. Her cardiovascular and respiratory systems were unremarkable. She had no upper incisors, and movements of neck and temporo-mandibular joints were normal. The lesion was involving the upper lip on the right side and covering half of the oral opening. Nasal passage on the right side was compressed by the lesion; however, left nostril was patent. It was impossible to visualize oropharyngeal structures for Mallampati airway grading as only the left half of the mouth could be opened. Chest X-ray showed thoracic scoliosis. X-rays of the cervical spine and soft tissue neck were both normal. Computed tomography scan of head/brain and echocardiography were normal limits. Relevant investigations were within normal limits. General anesthesia was planned for the procedure. As our patient was not convinced for awake intubation, we decided to intubate the patient under anesthesia. Difficult airway cart including fiberscope was kept ready. Patient was pre-oxygenated. We could not achieve adequate seal over nose and mouth with anatomical facemask, so we decided to use a Rendell Baker Soucek mask for ventilation kept over nose only for adequate seal to be achieved. Anesthesia was induced with 8% sevoflurane in oxygen delivered via a Rendell Baker Soucek mask kept over patient’s nose with the lips pursed, and adequate seal was achieved. When adequate depth of anesthesia had been achieved, ability to mask ventilate was judged using assisted ventilation, and propofol 30 mg with fentanyl 50 mcg were given intravenously. Oropharynx was topically anesthetized with 2 puffs of 10% lignocaine spray. Laryngoscopy with left molar approach was done using Macintosh blade #3 and after visualizing the glottis, the trachea successfully intubated with a 7 mm ID endotracheal tube. The peri-operative period was uneventful. Our backup plan was maintaining anesthesia using inhalational agents with the help of nasopharyngeal airway through left nostril and intubatng the trachea using left molar approach of laryngoscopy. Another plan was maintaining anesthesia using inhalational agents with the help of pediatric size endotracheal tube through right nostril after nasal decongestion and lubrication of the passage and intubating the trachea using fiberscope through other nostril. If this would not have been possible, we would have awakened the patient and counseled her to accept awake intubation later. Rendell Baker Soucek mask is used in pediatric patients because of good seal around contours of cheek and chin. The use of the mask for ventilation through mouth only, in a patient with nasal tumor, has been described.[1] The design of the mask can affect the effectiveness of ventilation.[2] Transparent disposable masks with cushion rims are most commonly used in anesthesia today. It is crucial to obtain a tight seal with the mask to prevent leaks. Leaks may result from an improperly-inflated cushion, improper mask size, presence of beard or abnormal facial anatomy. In this case, abnormal facial anatomy was responsible for ineffective ventilation with facemask. The ability to achieve adequate mask ventilation should always thus be assessed pre-operatively. In patients with expected difficult mask ventilation, the safest approach is to plan for an awake intubation. Flexible fiberoptic laryngoscopy is an effective tool for managing a difficult airway.[3] Left molar approach of laryngoscopy has been advocated in cases of difficult intubation, which is an unconventional technique, in which the blade is inserted from the left corner of the mouth. This approach has been shown to provide a better view of the glottis than the conventional midline approach in cases of difficult intubation.[4] We used this approach because only the left half of the mouth could be opened. Difficulties of left molar approach are requirement of a stylet and less availability of space. Despite improved laryngeal view, negotiation of tube may be difficult. The use of the laryngeal mask airway and other supraglottic devices like combitube, laryngeal tube should be encouraged when facemask ventilation is difficult.[5] These options were not possible in our case as only the left half of the mouth could be opened. Trans-tracheal jet ventilation may be considered when supraglottic ventilation devices fail, but the operator must be familiar with its use.[6] If all other measures fail to establish ventilation, cricothyrotomy or tracheostomy may be life-saving.

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          Most cited references6

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          Management of the difficult adult airway. With special emphasis on awake tracheal intubation.

          J Benumof (1991)
          Difficulty in managing the airway is the single most important cause of major anesthesia-related morbidity and mortality. Successful management of a difficult airway begins with recognizing the potential problem. All patients should be examined for their ability to open their mouth widely and for the structures visible upon mouth opening, the size of the mandibular space, and ability to assume the sniff position. If there is a good possibility that intubation and/or ventilation by mask will be difficult, then the airway should be secured while the patient is still awake. In order for an awake intubation to be successful, it is absolutely essential that the patient be properly prepared; otherwise, the anesthesiologist will simply fulfill a self-defeating prophecy. Once the patient is properly prepared, it is likely that any one of a number of intubation techniques will be successful. If the patient is already anesthetized and/or paralyzed and intubation is found to be difficult, many repeated attempts at intubation should be avoided because progressive development of laryngeal edema and hemorrhage will develop and the ability to ventilate the lungs via mask consequently may be lost. After several attempts at intubation, it may be best to awaken the patient, do a semielective tracheostomy, or proceed with the case using mask ventilation. In the event that the ability to ventilate via mask is lost and the patient's lungs still cannot be ventilated, TTJV should be instituted immediately. Tracheal extubation of a patient with a difficult airway over a jet stylet permits a controlled, gradual, and reversible (in that ventilation and reintubation is possible at any time) withdrawal from the airway. Significant advances in the management of the difficult airway have occurred in recent years. Eighty percent of the 127 references in this article were published after 1985. However, there is much more to learn with regard to recognition of the difficult airway, preparation of the patient for an awake intubation, new techniques of endotracheal intubation, and establishment of gas exchange in patients who cannot be intubated or ventilated by mask. As the anesthesiologist's ability to manage the difficult airway significantly improves, respiratory-related morbidity and mortality will decrease.
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            Use of paediatric face mask for adult ventilation in a patient with nasal tumour

            Sir, While managing difficult airway, the anaesthesiologist must be able to assess and anticipate the degree of difficulty and then select the method most likely to succeed. Mask ventilation is an essential component of airway management and the delivery of general anaesthesia. Successful mask ventilation provides anaesthesiologists with a rescue technique during unsuccessful attempts at laryngoscopy and unanticipated difficult airway situations. We are reporting a case of a big nasal tumour with impossible conventional mask ventilation successfully managed by ventilation with paediatric face mask covering the mouth only. A 14-year-old male was admitted to the ENT department with a large, round cell tumour of the nose. The patient was posted for excision of mass after routine laboratory investigations. During pre-anaesthetic checkup, we noted that the tumour was covering the whole nose, and the anterior nares were compressed. Other than the mass, airway assessment was unremarkable. No difficulty in intubation was anticipated. The possibility of tracheostomy was mentioned and consent taken. Difficult airway cart was kept ready. Because of the size of the tumour, it was not possible to ensure good facemask seal for initial ventilation. We thought of ventilating the patient through mouth only using paediatric-sized face mask (No. 2) [Figure 1]. After pre-oxygenation, we induced the patient with fentanyl and propofol. Check ventilation was done, and it was adequate through the small-sized mask. Intubation was done with succinylcholine. Rest of the period was uneventful. The patient was extubated on table after the procedure. Figure 1 Ventilation through small -sized mask Nasal tumour is one of the conditions associated with difficult or impossible mask ventilation. Airway management in a patient with nasal tumour is very challenging because of the inability to place a face mask. In some of these patients, however, tracheal intubation may be achieved easily. An alternative approach in this setting may be the use of laryngeal mask airway. Shimosaka et al.[1] reported the use of intubating laryngeal mask airway to maintain spontaneous respiration, followed by fibreoptic bronchoscopy for intubation, in a similar case. The frequency of inability to ventilate and intubate has been estimated at 0.01 to 2.0 per 10,000 anaesthetic administrations[2]; but with proper assessment and planning, such a situation can be prevented. In this particular case, we knew that correct conventional mask ventilation will not be possible, so we decided to use smaller mask covering the mouth only. Nagaro et al.[3] used paediatric mouth mask for fibreoptic nasal tracheal intubation in anaesthetised patients to prevent reduction in manoeuvrability of fiberoptic bronchoscope and endotracheal tube as seen while using conventional mask and diapharam for fiberoptic intubation. In this, ventilation and anaesthesia are maintained by an infant- or child-type seal mask applied only over the mouth with the aid of an oral airway during fibreoptic tracheal intubation, and fibreoptic nasal tracheal intubation is performed by another anaesthetist. Thus such types of cases can be managed in centres where fibreoptic bronchoscope is not available. If there are high chances that both ventilation and intubation will be difficult, airway should be secured while the patient is still awake. In managing difficult airway, proper assessment, preparation and well-organized approach will further bring down airway-related morbidity and mortality.
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              Another reason to choose the left molar approach of laryngoscopy: to spare the incisor teeth.

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                Author and article information

                Journal
                J Anaesthesiol Clin Pharmacol
                J Anaesthesiol Clin Pharmacol
                JOACP
                Journal of Anaesthesiology, Clinical Pharmacology
                Medknow Publications & Media Pvt Ltd (India )
                0970-9185
                2231-2730
                Apr-Jun 2013
                : 29
                : 2
                : 271-272
                Affiliations
                [1]Department of Anaesthesiology and Critical Care, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
                Author notes
                Address for correspondence: Dr. Teena Bansal, Department of Anaesthesiology and Critical Care, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India. E-mail: aggarwalteenu@ 123456rediffmail.com
                Article
                JOACP-29-271
                10.4103/0970-9185.111735
                3713690
                23878464
                14ce9ce6-c304-49f8-98ec-e8f05641a658
                Copyright: © Journal of Anaesthesiology Clinical Pharmacology

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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