|Year : 2008 | Volume
| Issue : 4 | Page : 440
Airway Management in Fixed Flexion Deformity using an Alternative Method of ILMA Insertion
Sudhir K Singh1, Veena Asthana2, YS Payal2, Sanjay Agrawal2, DK Singh2, Nidhi Srivastava3
1 Senior Resident, Department of Anaesthesia, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
2 Assistant Professor, Department of Anaesthesia, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
3 P.G. Student, Department of Anaesthesia, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
|Date of Acceptance||26-May-2008|
|Date of Web Publication||19-Mar-2010|
Department of Anaesthesia, Himalayan Institute of Medical Sciences, Dehradun
Source of Support: None, Conflict of Interest: None
Fixed flexion deformity is a sequel of burns and their release under anaesthesia pose difficulty during intubation. Various modalities are used for airway management in such cases. Here we present the successful airway management in a patient with post burn contracture who was managed with use of intubating laryngeal mask airway (ILMA) introduced in reverse direction with 180 0 rotation for insertion.
Keywords: Fixed flexion deformity, ILMA, 180 0 rotation technique
|How to cite this article:|
Singh SK, Asthana V, Payal Y S, Agrawal S, Singh D K, Srivastava N. Airway Management in Fixed Flexion Deformity using an Alternative Method of ILMA Insertion. Indian J Anaesth 2008;52:440
|How to cite this URL:|
Singh SK, Asthana V, Payal Y S, Agrawal S, Singh D K, Srivastava N. Airway Management in Fixed Flexion Deformity using an Alternative Method of ILMA Insertion. Indian J Anaesth [serial online] 2008 [cited 2020 Jan 20];52:440. Available from: http://www.ijaweb.org/text.asp?2008/52/4/440/60659
| Introduction|| |
Contracture of the neck is a equel of burns. These patients generally present to the hospital for release of contractures. Airway management in this setting is a challenge to anaesthesiologist owing to fixed flexion deformity resulting in nonalignment of oral, pharyngeal and laryngeal planes for intubations. Such patients are usually managed along the awake limb of difficult airway algorithm  . Here we present a case report of a patient with severe contracture of the neck with mouth opening of 2 fingers where ILMA insertion with a 180 degree rotation technique was successfully used for airway management.
| Case report|| |
A 27 year male presented to plastic surgery outpatient department of our hospital with history of post burn contractures of neck, chest and forearm [Figure 1]. Preoperative examination showed fixed flexion deformity with reduced mouth opening of two fingers [Figure 2]. General and systemic examinations were within normal limits. A preoperative assessment of difficult intubation was made. Patient was explained about the possibility of difficult intubation and need for tracheostomy if required.
On the day of surgery patient was premedicated with oral alprazolam 0.25 mg in morning to allay anxiety 2 hour before surgery. In the operating room patient was made to lie supine with the head adequately supported on pillows and routine monitoring like electrocardiogram, noninvasive blood pressure and pulse oximetry were attached. Difficult intubation cart was kept ready with the presence of surgeon for emergency tracheostomy if needed. Anaesthesia was induced with patient breathing spontaneously incremental concentration of sevoflurane in oxygen. After attaining sufficient depth of anaesthesia an Intubating Laryngeal Mask Airway (ILMA) number 4 was tried to be inserted but due to fixed flexion deformity its handle got stuck onto the chest hindering its passage into the oral cavity. Increasing the depth and maximally allowable extension of neck did not overcome the problem. ILMA insertion was reattempted with 180 0 rotation technique. Once the mask portion was inside the mouth up to its angulations it was rotated 180 0 , the ILMA slipped comfortably inside the mouth and cuff was inflated with 30 ml of air. Adequacy of ventilation was checked by absence of pericuff leak and square wave capnograph. A small bolus of propofol (20 mg) was then administered to deepen the plane of anesthesia for intubations. A normal flexomettalic tube (with short bevel) of size 7.5 mm was passed through the ILMA and patient was intubated successfully in the second attempt . Position of tube was confirmed by auscultation and capnography. Muscle relaxation was then instituted with vecuronium bromide 0.1 mg, ILMA was removed and maintenance of anaesthesia was done with N 2 O&O 2 (66:33), sevoflurane (2- 3%) and fentanyl 100mcg. Intraoperative period was uneventful. At the end of surgery neuromuscular blockade was reversed with neostogmine 2.5 mg and glycopyrrolate 0.4 mg, patient was, extubated and shifted to PACU.
| Discussion|| |
Difficult airway is a challenge to anaesthesiologist for maintenance of airway and ventilation during anaesthesia. Patients such as ours pose a real challenge for maintenance of airway and ventilation during anaesthesia. Use of standard laryngoscope is not possible in such cases due to non alignment of oral/ pharyngeal axis making intubation difficult. The use of awake limb of the airway algorithm is the only alternative left for intubation in such cases. Various options available for intubation in such cases are: awake fibreoptic intubation, LMA, ILMA, blind nasal intubation, retrograde intubation, tracheostmy. Use of fibreoptic intubation is the gold standard against which other techniques are compared. Efficacy of ILMA as ventilatory device and aid to blind intubation is well proven and comparable to fibreoptic intubation , . The advantages of ILMA are easy insertion in patient's with immobile neck  , better use as airway intubator  ,easy maneouver to adjust the position of mask in relation to glottic opening 
Success rate of blind tracheal intubation through ILMA varies between 89.5%-100% ,
ILMA is a rigid preformed device and a minimum distance between patient hard palate and anterior most part of chest/ neck is required for its action. This distance should be equal to shortest distance between the tip of mask portion and the machine end. In cases where this distance is reduced the machine end of ILMA cannot be lowered enough to align the pharyngeal surface of ILMA with hard palate. Thus when machine end impinges on anterior most part of chest the tip of mask portion of ILMA faces downwards and hits the lower incisors or gum. In our case also the distance between patient mouth and chest was reduced due to contracture.
Kumar et al  were the first to use the reverse technique of ILMA insertion in a cases of fixed neck deformity with very good result .
Success of LMA/ILMA insertion for airway management is determined by angle between oral, pharyngeal and larygeal axis first described by Ishimura, et al  . An angle greater than 90 degree is required for insertion of LMA/ILMA. Any condition where angle is smaller than 90 degree, alternative ways must be considered for intubation.
We have chosen inhalational induction with sevoflurane in this case to minimize the risk of sudden loss of airway. Propofol is also acceptable but chances of apnoea are higher. If desired depth of anaesthesia is achieved as with use of propofol or inhalational agent use of muscle relaxant is not required for ILMA insertion and intubation..
In conclusion we state that thorough understanding of difficulty and preparation for difficult airway should be meticulous before taking up such cases for surgery. Innovations can lead to high degree of success in difficult situations.
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[Figure 1], [Figure 2]