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LETTER TO EDITOR
Year : 2011  |  Volume : 55  |  Issue : 3  |  Page : 312-313  

Molar approach of intubation in a neonate with large intraoral swelling


Department of Anesthesiology and Critical Care, SN Medical College, Agra, Uttar Pradesh, India

Date of Web Publication7-Jul-2011

Correspondence Address:
Apurva Mittal
Department of Anesthesiology and Critical Care, SN Medical College, Agra, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.82657

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How to cite this article:
Mittal A, Dwivedi Y, Joshi K, Saxena A, Gupta A. Molar approach of intubation in a neonate with large intraoral swelling. Indian J Anaesth 2011;55:312-3

How to cite this URL:
Mittal A, Dwivedi Y, Joshi K, Saxena A, Gupta A. Molar approach of intubation in a neonate with large intraoral swelling. Indian J Anaesth [serial online] 2011 [cited 2019 Oct 17];55:312-3. Available from: http://www.ijaweb.org/text.asp?2011/55/3/312/82657

Sir,

A 24-day neonate, weighing 2.3 kg, presented with a swelling in the oral cavity, with difficulty in breast feeding. The swelling was small at birth which progressively increased over time. Local examination showed that the baby's mouth was wide open, due to a 3×4 cm cystic transilluminant mass [Figure 1] occupying the entire oral cavity. The origin of the swelling was difficult to ascertain, but was occupying the ventral aspect of tongue and pushing the dorsum of tongue upwards towards the palate. Clinically, a provisional diagnosis of mucus retention cyst or lymphangioma was made. Surgical excision of cyst was planned under general anaesthesia.
Figure 1: A large intraoral swelling in a neonate

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Patient was premedicated with atropine 0.01 mg IV, and induced under inhalational anaesthesia using oxygen and gradually increasing concentration of halothane. After achieving adequate depth, endotracheal intubation was attempted which proved unsuccessful. As adequate mask ventilation could be done, we planned for intubation using suxamethonium. Molar approach of laryngoscopy using Mackintosh blade was done with successful intubation. Anaesthesia was maintained with oxygen, N 2 O, halothane, and atracurium. Surgical excision of cyst was accomplished successfully with uneventful intraoperative period. The patient was extubated and shifted to NICU for 24 h and had smooth postoperative recovery.

Difficult laryngoscopy is encountered more often in cases presenting with intraoral swelling, as they encroach and physically occupy the oral cavity making glottic visualization and manoeuvring of the endotracheal intubation difficult. [1] Various techniques are available to secure the airway in adults, but success and safety of these techniques in the paediatric age group with large oral swelling has not been established. Tracheostomy is impractical in early stages and awake fibreoptic intubation is not manageable in children. [2]

For molar approach of intubation, Mackintosh blade size 1 was introduced from right side of mouth and advanced below the tongue up to the molar space pushing the tongue medially and directing tip of the blade postero-medially under the base of the tongue until the epiglottis was seen. The endotracheal tube was then introduced and advanced from the corner of the mouth from the point behind the molar space through the glottic opening under direct vision. [3],[4]

This approach reduces the distance from the patient's teeth to the larynx and thus prevents intrusion of intraoral, maxillary structures into the line of vision and also avoids a large volume of the tongue remaining anterior to the blade compared to the midline approach. [3]

In cases of anticipated difficult airway due to intraoral masses, where the midline technique of laryngoscopy can be traumatic or can cause bleeding, molar approach is a better advocated technique. This is very easy, reliable, and rewarding but should be practiced on normal patients for easy application in actual difficult cases. [1]

 
   References Top

1.Potdar M, Patel RD, Dewoolkar LV. Molar intubation for Intra oral swellings: Our Experience. Ind J Anaes 2008:52;861.   Back to cited text no. 1
    
2.Vashist M, Miglani HP. Approach to difficult and compromised airway in neonatal and paediatric age group patients. Ind J Anaes 2008;52:273-81.  Back to cited text no. 2
    
3.Henderson JJ. The use of Paraglossal straight blade laryngoscopy in difficult tracheal intubation. Anaesthesia 1997:52;552-60.  Back to cited text no. 3
    
4.Yamamoto K, Tsubokawa T, Ohmura S, Itoh H, Kobayashi T. Left molar approach improves the laryngeal view in patients with difficult laryngoscopy. Anesthesiology 2000;92:70-4.  Back to cited text no. 4
    


    Figures

  [Figure 1]


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