Indian Journal of Anaesthesia

: 2008  |  Volume : 52  |  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

Correspondence Address:
Sanjay Agrawal
Department of Anaesthesia, Himalayan Institute of Medical Sciences, Dehradun


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.

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;52:440-440

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 22 ];52:440-440
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Full Text


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 [1] . 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.


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 [2],[3] . The advantages of ILMA are easy insertion in patient's with immobile neck [4] , better use as airway intubator [5] ,easy maneouver to adjust the position of mask in relation to glottic opening [6]

Success rate of blind tracheal intubation through ILMA varies between 89.5%-100% [7],[8]

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 [7] 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 [9] . 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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