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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 1  |  Page : 90 Table of Contents     

Retrograde Intubation in Temporomandibular Joint Ankylosis-A Double Guide Wire Technique


Professor and Head of Anaesthesia, J.N.Medical College & KLESH & MRC, Belgaum.

Date of Acceptance20-Nov-2007
Date of Web Publication19-Mar-2010

Correspondence Address:
Vitha K Dhulkhed
Plot No. 7229, Sector No.10, Mal Maruti Extension, Belgaum- 590016, Karnataka State.

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Source of Support: None, Conflict of Interest: None


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Intubating a patient with temporomandibular joint ankylosis is always a challenge particularly when fibreoptic laryngo­scope is not available. In a 20-year-old male patient we successfully carried out endotracheal intubation with 7 mm portex cuffed PVC tube with the help of two flexible J tipped guide wires. One guide wire was passed into the airway from cricothyroid puncture site and another from subcricoid site. Both were brought out through the nose. The first guide wire was used for retracting the epiglottis and the second as a guide for passing the endotracheal tube.

Keywords: Retrograde intubation; Temporo mandibular joint ankylosis; Guide wire, Difficult intubation; Difficult airway


How to cite this article:
Dhulkhed VK. Retrograde Intubation in Temporomandibular Joint Ankylosis-A Double Guide Wire Technique. Indian J Anaesth 2008;52:90

How to cite this URL:
Dhulkhed VK. Retrograde Intubation in Temporomandibular Joint Ankylosis-A Double Guide Wire Technique. Indian J Anaesth [serial online] 2008 [cited 2019 Nov 13];52:90. Available from: http://www.ijaweb.org/text.asp?2008/52/1/90/60607


   Introduction Top


Intubating a patient with temporomandibular joint (TMJ) ankylosis is always a challenge. A number of tech­niques are available which include blind nasal intubation, retrograde intubation using a guide wire, intubating with the help of a fibreoptic laryngoscope and tracheostomy. Since the first description of retrograde intubation in 1960 [1] several modifications have been reported. [2],[3] .

We use flexible J tipped guide wire for this tech­nique. During the procedure the epiglottis often obstructs the tip of the endotracheal tube when it is being passed over the guide wire. In a case of TMJ ankylosis we used a second guide wire to hold back the epiglottis from obstructing the tube during retrograde intubation.


   Case report Top


A 20-year ASA grade I male (weight 43 kg) pre­sented with inability to open the mouth since 12 years. Mouth opening was 2 mm. He gave a history of swelling of left jaw from which pus was drained. Since then he had trismus. He was operated which resulted in mouth opening of 2 fingers but it did not last long. From history, clinical findings and investigations he was diagnosed as a case of TMJ ankylosis on left side. He was to undergo osteoarthrotomy and reconstruction with costochondral graft on left side. His neck mobility was normal. There was no history of breathlessness. Fibreoptic laryngoscope was not available. We planned to use retrograde intuba­tion technique with the help of two J tipped guide wires. The procedure and the possibility of resorting to tracheo­stomy were explained to the patient in his native lan­guage. His consent was taken. The J tipped guide wires were procured from cardiac catheterisation laboratory. (DE ROYAL CRITICAL DISPUSABLES. INC.035". Fixed core PTFE coated guide wire). An ENT surgeon was asked to be on stand by for possible tracheostomy in the event of an emergency.

In the operating room 18 G IV cannula was placed in the left arm for crystalloid infusion. Monitoring included ECG, pulse oximeter and capnography. Atropine 0.5 mg was given intravenously (IV). Diazepam 10 mg and pen­tazocine 30 mg were administered in incremental doses. Xylometazoline nasal drops were instilled into each nos­tril. Topical 4% lidocaine was sprayed into each nostril. Bilateral superior laryngeal nerve block was carried out with 1% lidocaine. Airway reflexes were additionally blunted by instilling 4% lidocaine into the trachea via 24 G needle, which was introduced into the trachea through the cricothyroid puncture. Giving a slight downward tilt to the patient facilitated its upward spread.

Under aseptic precautions a 16 G cannula was passed into the trachea by puncturing the cricothyroid membrane and directed upwards. Through the cannula the flexible J tipped guide wire was introduced into the trachea and threaded upwards. It easily negotiated the curved pathway of the larynx, pharynx, nasopharynx and nasal passage and came out of the nostril. C-arm image intensifier was used to visualize the procedure[Figure 1]. The cannula was removed. Similarly from subcricoid puncture site a second guide wire was brought out of the nose, the first guide wire being held taut by the assis­tant between the two ends to prevent the second guide wire from coiling around the first[Figure 2] and [Figure 3]. Since it came out through the mouth it was withdrawn and rein­troduced with slight rotation and could be brought out of the nostril without further difficulty.

A 7mm. cuffed endotracheal tube was passed over the second guide wire through its Murphy eye. The ends of both guide wires were held sufficiently taut and the endotracheal tube was gently glided down over the guide into the trachea[Figure 4] and [Figure 5]. Its passage was smooth. Both the guide wires were removed. The tube was ad­vanced further down. IPPV was started manually. Aus­cultating the chest and monitoring EtCO 2 confirmed tube position. We gave pancuronium and thiopentone sodium. Anaesthesia was maintained with IPPV using oxygen, nitrous oxide and halothane 0.5 to 1%. At the end of surgery the mouth opening was satisfactory. Residual neuromuscular block was reversed. The trachea was extubated when the patient was awake, responding to oral commands and airway reflexes were present. His subsequent recovery was uneventful.


   Discussion Top


In TMJ ankylosis the technique of blind nasal intu­bation was traditionally recommended. [4] It can fail and repeated attempts may injure the involved structures resulting in complications like bleeding airway obstruc­tion etc. The technique of retrograde intubation was origi­nally described in 1960. Since then several modifications have been reported.

Use of fibreoptic laryngoscope may be the method of choice in difficult airway. In the presence of bleeding this may also end up in failure. [5],[6] . In many centers the scope may not be available. Alternative options will be necessary in such situations

Passing a retrograde guide wire or a catheter through a cricothyroid puncture and using it as a guide is a useful technique in cases of difficult airway. [7],[8],[9] . Tradi­tional technique of retrograde intubation involves sev­eral steps. Through cricothyroid puncture an epidural catheter is passed into the airway and brought out of the mouth. In the next step another catheter is passed into the nose and brought out in the same way. The two are tied together to be used as guide for intubation. In an­other variation the epidural catheter is passed through cricothyroid puncture into the pharynx. It is retrieved from the pharynx by using a pharyngeal loop or a suc­tion catheter passed through the nose. [6],[10] . Straight guide wire removed from a central venous catheter set is also used and passed with the assistance of a fluoroscope [11]

J tipped guide wires are regularly used in urology and cardiac catheterization laboratory for negotiating bends in curved and tortuous pathways. This prompted us to use the guide wire in retrograde intubation tech­nique. It easily negotiates the curved passage of larynx, pharynx, nasopharynx, nasal passage and comes out of the nostril without much difficulty. Fluoroscope will be helpful but not a must in this technique.

However in our experience of using the single guide wire technique the endotracheal tube during its passage over the guide wire was often obstructed by epiglottis. In this instance the tube had to be withdrawn and rein­troduced with turning movement. Using a smaller size tube was also necessary in some instances.

To hold back the epiglottis and preventing it from obstructing the tip of the endotracheal tube we conceived the idea of using a second guide wire. Here one guide wire is used for guiding the endotracheal tube whereas the other wire helped in retracting the epiglottis.

There is scope for further modification. The guide wire used for retracting the epiglottis can be brought out through the mouth instead of nose, which may help in better retraction.

To conclude, use of flexible J tipped guide wire for retrograde intubation makes it a one step procedure, since it negotiates the bends and curves in the airway without much difficulty. The use of second guide wire helps re­tracting the epiglottis to make the passage of the endot­racheal tube into the larynx easier.

 
   References Top

1.Butler F S, Cirillo A A. Retrograde tracheal intubation. Anesth Analg 1960; 39: 333-338.  Back to cited text no. 1      
2.Powel W F, Ozdilt. A translaryangeal guide for tracheal intuba­tion. Anesth Analg 1967;46: 231-234.  Back to cited text no. 2      
3.Roberts K W, New use for Swan Ganz introducer wire. Anesth Analg 1981; 60:67.  Back to cited text no. 3      
4.Williamson R. The airway decides the anaesthetic approach before tracheal intubation. Br J Anaesth 1993;70:601..  Back to cited text no. 4      
5.Borland LM, Swan DM, Left S. Difficult pediatric endotra­cheal intubations: a new approach to the retrograde technique. Anesthesiology 1981; 55: 577-8.  Back to cited text no. 5      
6.Arya VK, Dutta A, Chari P. Difficult retrograde endotracheal intubation: the utility of a pharyngeal loop. Anesth Analg 2002; 94: 470-3.  Back to cited text no. 6      
7.Waters DJ. Guided blind endotracheal intubation: for patients with deformities of the upper airway. Anaesthesia 1963;18: 158-62.  Back to cited text no. 7  [PUBMED]    
8.Powell WF, Ozdil T A. Trans laryngeal guide for tracheal intu­bation. Anesth Analg 1967; 46: 231-4.  Back to cited text no. 8      
9.Barriot P, Riou B. Retrograde technique for tracheal intubation in trauma patients. Crit Care Med 1988; 16: 712-3.  Back to cited text no. 9  [PUBMED]    
10.Bhattacharya P, Biswas BK, Baniwal S. Retrieval of a retro­grade catheter using suction, in patients who cannot open their mouths. Br J Anaesth 2004; 92:888-90.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Biswas B K, Bhattacharya P, Joshi S, Tuladhar U R, Baniwal S. Fluoroscope aided retrograde placement of guide wire for tracheal intubation in patients with limited mouth opening. Br J Anaesth 2005;94:128-131.  Back to cited text no. 11      


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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