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LETTERS TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 3  |  Page : 240-241  

Impression tray - A modest tool as an intubation aid


1 Department of Anaesthesiology, Muthumeenakshi Hospitals, Pudukkottai, Tamil Nadu, India
2 Department of Anaesthesiology, Kauvery Hospitals, Trichy, Tamil Nadu, India
3 Department of Anaesthesiology, University of Manitoba, Winnipeg, Canada

Date of Web Publication7-Mar-2019

Correspondence Address:
Dr. Khaja Mohideen Sherfudeen
Department of Anaesthesiology, Muthumeenakshi Hospitals, South 4th Street, Marthandapuram, Pudukkottai - 622 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_694_18

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How to cite this article:
Sherfudeen KM, Kaliannan SK, Jeyakumar SM, Ravichandran R P. Impression tray - A modest tool as an intubation aid. Indian J Anaesth 2019;63:240-1

How to cite this URL:
Sherfudeen KM, Kaliannan SK, Jeyakumar SM, Ravichandran R P. Impression tray - A modest tool as an intubation aid. Indian J Anaesth [serial online] 2019 [cited 2019 May 27];63:240-1. Available from: http://www.ijaweb.org/text.asp?2019/63/3/240/253687



Sir,

A 16-year-old girl was admitted with a history of road traffic accident and facial bone fractures. She sustained Le Fort II fracture with dentoalveolar fracture involving upper and lower incisors. Intrusion of both upper canines were present. Computed tomography of the brain and neck was normal. Airway examination revealed decreased mouth opening because of pain. Fractured premaxillary segment with four incisors was mobile. Both upper canines were not visualised. There was no active bleeding or signs on airway compromise. Neck movements were adequate. Next day she was posted for microplating of maxilla and arch bar fixation in both upper and lower incisors. General anaesthesia with nasotracheal intubation was planned. On the day of surgery 0.025%, xylometazoline drops were instilled into both nostrils. After attaching electrocardiogram, non-invasive blood pressure and pulse oximetry, anaesthesia was induced with intravenous (IV) fentanyl 100 μg, midazolam 2 mg, glycopyrrolate 0.2 mg, and propofol 100 mg. After confirming ventilation and adequate mouth opening, vecuronium 5 mg IV was given. Maxillary impression tray was gently placed over maxillary teeth [Figure 1]. A flexometallic tube of internal diameter 7 mm was inserted into left nostril and with gentle laryngoscopy (size 3 macintosh) it was guided into trachea. Interincisor space was adequate and there was no difficulty in intubation. Postintubation impression tray was removed. The maxillary segment was undisplaced with no bleeding. Throat pack was placed. Surgery and extubation was uneventful.
Figure 1: Image of the impression tray in position over the maxillary segment

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Common facial injuries involve fracture to one or more of the bones of the facial skeleton. High-force injuries causing fractures of the mandible or maxilla are likely to cause airway compromise. Anaesthesia for such cases present challenges to the anaesthetist. If difficult airway is anticipated, then awake fibreoptic intubation is the technique of choice. Other techniques, such as awake oral intubation or blind nasal intubation after topicalising the airway, can be tried in experienced hands.[1]

Our patient had a mobile premaxillary segment and no other signs of difficult airway. Hence, we decided to do gentle direct laryngoscopy for securing airway. But sometimes during difficult laryngoscopy, the anterior maxillary teeth are wrongly used as a fulcrum resulting in dental injuries. This trauma can displace the mobile maxillary segment resulting in fresh bleed and worsening airway.

Dental guard have been successfully used by otolaryngologists in suspension laryngoscopy and by anaesthesiologists during intubation in patients with loose tooth. Dental guards decrease the transmitted pressure of the laryngoscope to the upper incisors.[2] So, dental guard could be useful in our patient with mobile maxillary segment. Instead we used maxillary impression tray [Figure 2]. Impression tray is used by dentists to take impressions of teeth. It is strong compared with dental guards because it is made of metal. Hence, it was better than dental guard in preventing transmission of forces to the upper incisors in case laryngoscopic blade rests on incisors. The edges of impression tray were also smooth; hence, there was no injury to oral mucosa. The concern with use of impression tray is that it decreases the interincisor space, which may lead to difficulty in intubation. The impression tray we used was maxillary impression tray which has a palatal segment. The mandibular impression tray has no palatal segment. So, using mandibular impression tray for intubation would result in increased intraoral space compared with using maxillary impression tray.
Figure 2: Impression tray

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sood J. Maxillofacial and upper airway injuries anaesthetic impact. Indian J Anaesth 2008;52:688-98.  Back to cited text no. 1
    
2.
Ray BR, Khanna P, Anand RK, Baidya DK. Dental guards: An alternative solution for loose tooth. J Anaesthesiol Clin Pharmacol 2013;29:424-5.  Back to cited text no. 2
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