Difficult airway management in a maxillofacial and 2004 Journal of Oral and

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J Oral Maxillofac Surg
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Difficult intubation, however uncommon it may be,
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510 AIRWAY MANAGEMENT
ains the greatest challenge in the administration
anesthesia. The prevalence of difficult laryngos-
py (Cormack and Lehane grades 3 and 4) has
en estimated to be 1% to 2%.1-3 Neck contrac-
es and fixed cervical spine pose considerable
eived from the Department of Anaesthesiology and Critical
e, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences,
yana, India.
*Associate Professor.
†Professor and Head of Department.
‡Lecturer.
§Former Senior Resident.
Address correspondence and reprint requests to Dr Saini: 26/
w 8 FM, Medical Enclave, Rohtak-124001, Haryana, India; e-mail:
ita_saini12@yahoo.com.
004 American Association of Oral and Maxillofacial Surgeons
8-2391/04/6204-0091$30.00/0
:10.1016/j.joms.2003.08.019
rvical spine injury or disease, the incidence of
ficult intubation may be as high as 20%.4
Intubating laryngeal mask airway (ILMA) is a
vel device for use in cases of difficult or failed
ubation, especially in patients with cervical
ine disease, because it requires minimal head and
ck manipulations on insertion. Burn-induced cer-
al contractures present a unique challenge in
way management. We present here a case of
ficult intubation that was successfully managed
ing ILMA, which allows laryngeal mask place-
nt and subsequent endotracheal intubation us-
the ILMA as a guide.
port of a Case
30-year-old diminutive woman weighing 60 kg who
tained facial burns 10 years earlier was scheduled for
release of neck contracture. Her mouth opening was
ited to approximately 20 mm, and she had limited
ck movements, extension, and flexion (Fig 1). Difficult
510-513, 2004
Difficult Airway Management in a
Maxillofacial and Cervical Abnormality
With Intubating Laryngeal Mask Airway
Savita Saini, MS,* Sarla Hooda, DA, MD,†
Sachdeva Nandini, MD,‡ and Charoo Sekhri, DA§
ondary to damage of the zygomaticofacial
anch of the zygomatic nerve. Anatomically, the
gomatic nerve, 1 of the 3 branches of the maxil-
y nerve, leaves the maxillary in the pterygopala-
e fossa. The largest cutaneous branch, the zygo-
ticofacial branch, appears separate from the
er zygomaticotemporal branch and exits from
small foramen on the lateral aspect of the zygo-
tic bone to supply a limited region of skin ex-
ding upward toward the lateral corner of the
elids.10 This branch could be impaired by strong
ctromagnetic waves or overheating caused by
ctrocautery in the deep structures anterior and
dial to the TMJ.
ferences
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joint arthroscopy: A 6-year multicenter retrospective study of
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int
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int
of
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inc
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thr
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2).
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by
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eve
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or
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dif
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SAINI ET AL 511
ubation was anticipated. Because the patient was un-
lling to agree to awake intubation, she was planned for
ubation of trachea through the ILMA, after induction
anesthesia. She was premedicated with alprazolam
5 mg 2 hours preoperatively, and anesthesia was in-
ced with 100% oxygen and sevoflurane in gradually
reasing concentrations from 0.5% to 8%. Patency of
airway could be attained only with considerable jaw
ust maneuver, and an assistant was required to main-
n unobstructed airway. After achieving sufficient jaw
axation, a size 3 ILMA could be passed with ease (Fig
An airtight seal was achieved by inflating the cuff with
mL air. Owing to the extensive downward pull caused
the contracture, ventilation, even through the ILMA,
uired sustained jaw thrust, thus maintaining the same
sition. The trachea was intubated with a size 7.0-mm
ernal diameter (ID) silicone-cuffed tracheal tube that
s passed through the ILMA (Fig 3). Correct placement
the tracheal tube was confirmed by auscultation of the
est. The ILMA was removed over the tube (Figs 4, 5).
URE 1. Patient with facial burns showing contracture neck with
ted mouth opening.
FIGURE 2. Showing introduction of ILMA.
e remainder of the anesthesia management was un-
ntful.
scussion
Difficult airway remains a challenge to the anes-
siologist even today. Neck contracture makes
ubation more difficult by restricting head and
ck mobility. Head and neck movements are con-
indicated in patients with cervical spine injury
fear of further aggravating the neurologic defi-
.5,6 Manual in-line stabilization of the neck is
eded, but this may make the angle between the
al and pharyngeal axes more acute, thereby ob-
ring the view on laryngoscopy and posing a
ficulty in the placement of an endotracheal
e.7,8
The alternatives routinely available to an anesthe-
logist in a case of difficult intubation include
URE 3. Showing ETT being inserted through the ILMA and being
nected to the breathing circuit.
URE 4. Showing ILMA being removed over the stabilizing rod
ile the ETT is in situ.
aw
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512 AIRWAY MANAGEMENT
ake fiberoptic intubation, blind nasal intubation,
cothyroidotomy, indirect laryngoscopy with the
llard laryngoscope, Combitube (The Kendall Co
, Basingstoke, England), blind oral intubation via
Augustine guide, and LMA. Cricothyroidotomy
d combitube are emergency procedures for air-
y maintenance. Awake fiberoptic intubation, the
ll-accepted technique for difficult intubation,
n be uncomfortable and stressful for the patient
d requires expertise, and hence may not be suit-
le for emergency patients and those who refuse
be intubated awake.
The standard LMA can be used to enable ventila-
n of the lungs in patients in whom tracheal
ubation has failed, but it does not prevent aspi-
ion and thus is not recommended for patientsfor
om the risk of aspiration is high. Blind intuba-
n can be achieved through the standard LMA, but
admits a cuffed tube with a maximum internal
meter of 6.0 mm and has a success rate of 30% to
% compared with ILMA, which can be used as a
nduit for a tracheal tube of up to 8.0-mm ID with
uccess rate of 82% to 99.3%.7,9-15
In their report on the initial assessment of per-
mance of ILMA in 100 patients, Kapila et al12
nd that the trachea was intubated successfully in
patients. Of the 7 failed intubations, 5 occurred
the first 20 patients, showing the presence of a
rning curve in acquiring expertise in the use of
A.
The ILMA is a remarkable device for failed or
ficult intubation; it does not require movement
cervical spine and can be placed with the head
d neck in neutral position.16 Moller and col-
gues examined 17 cases of blind intubation
ough the ILMA in patients with disorders of
rvical spine who were wearing a stiff neck collar.
URE 5. Showing ILMA being removed while the ETT is being
ilized with the other hand.
the majority of these patients (16) stiff neck
llar produced no serious obstacle to insertion,
ntilation, and blind intubation through the
A.16
Wakeling and Nightingale,17 however, in their
dy on 10 patients, have shown that ILMA inser-
n and ventilation are difficult in patients with
ck trauma or those wearing a neck collar or with
coid pressure. This study used only 10 cases for
ir review with patients wearing a semirigid cer-
al collar; only 2 patients were intubated success-
ly.
On the contrary, we found the ILMA to be of
mense value in many of our cases of difficult or
led intubation. In addition, it requires mouth
ening of only 2 cm and allows ventilation to
ntinue during attempts of intubation. The ILMA
uld easily be inserted, and subsequent negotia-
n of the tracheal tube through it was accom-
shed without any difficulty. We recommend that
ILMA should be a part of the “emergency diffi-
lt intubation tray” so that it can be used for cases
difficult or failed intubation as it allows tracheal
e placement with ease and success.
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2000
SAINI ET AL 513
	Difficult Airway Management in a Maxillofacial and Cervical Abnormality With Intubating Laryngeal Mask Airway
	Report of a Case
	Discussion
	References