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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 2  |  Page : 196-198 Table of Contents     

Modified Technique of Retrograde Intubation in TMJ Ankylosis


1 Associate Professor, Department of Anaesthesiology, Goa Medical College, Bambolim, Goa - 403202, India
2 Junior Resident, Department of Anaesthesiology, Goa Medical College, Bambolim, Goa - 403202, India
3 Senior Resident, Department of Anaesthesiology, Goa Medical College, Bambolim, Goa - 403202, India

Date of Acceptance25-Feb-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Shaila Kamat
"Shaila" Green Valley Colony, Chogum Road, Alto - Porvorim, Goa 403521
India
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Source of Support: None, Conflict of Interest: None


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We are presenting a case report on the anaesthetic management of a case of ankylosis of temporomandibular joint for corrective surgery in a 7 year old child. Anticipated difficult airway in paediatric population has always been a perplexing problem, awake fibreoptic intubation almost impossible due to obvious difficulties with co-operation. Here we are describing a new approach to this problem, in which the patients were kept under GA with spontaneous ventilation while retrograde intubation was done quite comfortably by the conventional method.

Keywords: Paediatric difficult airway; Retrograde intubation; Railroading


How to cite this article:
Kamat S, Raju M, Gupta R, Kamat S. Modified Technique of Retrograde Intubation in TMJ Ankylosis. Indian J Anaesth 2008;52:196-8

How to cite this URL:
Kamat S, Raju M, Gupta R, Kamat S. Modified Technique of Retrograde Intubation in TMJ Ankylosis. Indian J Anaesth [serial online] 2008 [cited 2019 Aug 25];52:196-8. Available from: http://www.ijaweb.org/text.asp?2008/52/2/196/60621


   Introduction Top


Successful intubation can be accomplished in a majority of patients via direct laryngoscopy, but some­times tracheal intubation may be difficult or impossible mainly due to limited mouth opening or any other ana­tomical abnormality. Retrograde tracheal intubation is a possible technique that seems to be simple and quick in experienced hands [1] and that is indicated in various clini­cal situations [2] , including cervical and facial trauma and limited mouth opening 3 . However, the success rate of the retrograde tracheal intubation is variable [4] .

In dealing with our case, where keeping patient awake was not an option at all, we have opted for a new approach.


   Case report Top


A 7-year-old girl presented with complaints of re­stricted mouth opening of 6 month duration without sig­nificant illnesses. Systemic examination was within nor­mal limits. Patient weighed 16 kg. Airway examination revealed mouth opening of just one finger. Mentohyoid and mentothyroid distances were adequate.

Radiological examination ruled out any significant narrowing of airways and the absence of hypertrophied adenoids. Relatives were explained that the technique may fail and consent for tracheostomy was taken. Apart from the usual preparation for difficult intubation, we used the following items for retrograde intubation:

  • Improvised nasopharyngeal airway: We have im­provised and used one size smaller endotracheal tube as a nasopharyngeal airway. [Figure 1]& [Figure 2]
  • J-tipped vascular guide-wire: J-tipped vascular guide-wire, 70 cm in length and 0.6-0.8 in diameter [B Braun Melsungen].
  • 16 G needle: Estimate approximate anteroposte­rior depth of the trachea according to the age. From the tip of the needle mark half the estimated an­teroposterior depth of the trachea with tape, which acts as a guard and prevents injury to the posterior wall of the trachea.
  • Sets for emergency cricothyroidotomy and tra­cheostomy were kept ready.
  • Monitoring with SpO 2 , EtCO 2 , ECG and NIBP was done.
Plan was to go for a smooth induction with mini­mum trauma to the airway and to maintain deep plane of anaesthesia taking care to avoid excessive hypoventilation. The patient was premedicated with glycopyrrolate 10 mcg.kg -1¸dexamethasone 0.4mg.kg -1 , hydrocortisone 5 mg.kg -1 , ondansetron 50 mcg.kg -1 , midazolam 0.03 mg.kg -1 , pethidine 0.3 mg.kg -1 , given in­travenously 5 minutes before induction on the table. Xylometazoline nasal drops were used to decrease the incidence of epistaxis. Nasal passages were lubricated with lidocaine (2%) jelly.

Induction was done with propofol 2mg.kg -1 slowly till the patient went to sleep. Plane of anaesthesia was deepened with isoflurane and concentration was in­creased gradually. Ringer lactate infusion was started to counteract the hypotension secondary to high con­centrations of isoflurane. Improvised nasopharyngeal air­way was passed in the right nostril up to the marked portion and fixed properly. Jackson-Ree's circuit was attached and 100% oxygen and inhalation agent contin­ued. We maintained patient on spontaneous ventilation with maximum concentration of inhalation agent. High concentration was given to depress upper airway& la­ryngeal reflexes along with relaxation of the cords. This deeper plane was maintained until successful intubation. After achieving deep plane of anaesthesia, 16 G needle was passed carefully, piercing the cricothyroid mem­brane not beyond mark on the needle to avoid trauma to posterior tracheal wall. The entry into trachea was con­firmed by aspirating air. 2ml of 2% lidocaine was in­jected through it intra-tracheally.

The J tip of the guide wire was introduced through the 16 G needle and slowly advanced till it was retrieved through nostril. In our experience guide wire always comes out through either nostril but not through the mouth, because guide wire takes path of least resistance which is along the curve of the posterior pharyngeal wall. [Figure 3]

Another endotracheal tube was passed and rail­roaded over the guidewire with beveled end of the en­dotracheal tube facing posterior during mounting, to fa­cilitate entry through the glottis. Confirmation of endot­racheal tube position was done by capnography and aus­cultation of bilateral breath sounds, and then the guidewire was removed.

Muscle relaxant-pancuronium 0.08mg.kg -1 was given and anaesthesia continued with oxygen,nitrous oxide and isoflurane. Repeat dose of pethidine 0.7 mg.kg­1 IV was administered. At the end of surgery, after thor­ough suctioning, patient was reversed with neostigmine and glycopyrrolate and extubated in lateral position.


   Discussion Top


Described in the early 1960s, retrograde tracheal intubation is an alternative technique for difficult airway management [5] . However although retrograde tracheal intubation is simple& reliable method in experienced hands [6] it is not often used [7],[8] ..

Flexible fibreoptic bronchoscope is the method of choice for coping with difficult tracheal intubations. Compared to flexible fibreoptic bronchoscope, retrograde tracheal intubation is a slightly invasive procedure but with limited complications and we feel is quite practi­cal where facilities for fibreoptic intubation are not avail­able or not feasible.

Retrograde tracheal intubation is an uncomfortable and traumatic experience in the awake patient. This pro­cedure calls for lot of understanding& co-operation, which is not practical when dealing with paediatric cases. Our modified technique of retrograde intubation helps in circumventing this difficulty because patient remains comfortable under GA throughout procedure.

Success rate of our modified rail roading technique is attributed to the benefits of the use of improvised na­sopharyngeal airway to maintenance of deeper plane of anaesthesia throughout the procedure, providing more time to attempt intubation and easier in retrieving guide wire. It also avoids the problem of patient becoming light as with mask ventilation, when mask has to be re­moved for retrieving or maneuvering the guide wire. There is no time restraint involved as there was no prob­lem of patient becoming light as the delivery of the an­aesthetic agent could be easily continued till intubation.

Although there are some complications mentioned in the literature like bleeding from nose or from the site of cricothyrotomy, minimal subcutaneous emphysema, infections like pretracheal abscess, airway trauma. We have not encountered any complications in our case. Unfortunately, because of the high purchase and main­tenance costs of fibreoptic devices, few centers have such facilities. Thus, in an emergency scenario, retro­grade nasal intubation with an improvised nasal airway could be a suitable alternative when fibreoptic broncho­scope is not available.

 
   References Top

1.Van Stralen DW, Rogers M, Perkin RM, Fea S. Retrograde intuba­tion training using a mannequin. Am J Emerg Med 1995; 13:50-2.  Back to cited text no. 1  [PUBMED]    
2.Harrison W, Bertrand M, Andeweg S, Clark J. Retrograde intu­bation around an in situ Combitube: A difficult airway manage­ment strategy. Anesthesiology 2005; 102:1061-2.  Back to cited text no. 2      
3.Bhattacharya P, Biswas BK, Baniwal S. Retrieval of a retro­grade catheter using suction, in patients who cannot open their mouths. Br J Anaesth 2004; 92:888-901.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Gill M, Madden MJ, Green SM. Retrograde endotracheal in­tubation: An investigation of indications, complications, and patient outcomes. Am J Emerg Med 2005; 23:123-6.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.SFAR. Intubation difficile, expertise collective. Ann Fr Anesth Reanim 1996; 15: 207-14.  Back to cited text no. 5      
6.Levitan RM, Kush S, Hollander JE. Devices for difficult air­way management in academic emergency departments: Re­sults of a national survey. Ann Emerg Med 1999; 33:694-8.  Back to cited text no. 6  [PUBMED]    
7.Ezri T, Konichezky S, Geva D, Warters RD, Szmuk P, Hagberg C. Difficult airway management patterns among attending anaesthetists practising in Israel. Eur J Anaesthesiol 2003; 20:619-23.  Back to cited text no. 7  [PUBMED]    
8.Jenkins K, Wong DT, Correa R. Management choicefor the difficult airway by anesthesiologists in Canada. Can J Anaesth 2002; 49:850-6.  Back to cited text no. 8  [PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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