|Year : 2008 | Volume
| Issue : 2 | Page : 196-198
Modified Technique of Retrograde Intubation in TMJ Ankylosis
Shaila Kamat1, Mithun Raju2, Rachita Gupta3, Sahish Kamat2
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 Acceptance||25-Feb-2008|
|Date of Web Publication||19-Mar-2010|
"Shaila" Green Valley Colony, Chogum Road, Alto - Porvorim, Goa 403521
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
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  and that is indicated in various clinical situations  , including cervical and facial trauma and limited mouth opening 3 . However, the success rate of the retrograde tracheal intubation is variable  .
In dealing with our case, where keeping patient awake was not an option at all, we have opted for a new approach.
| Case report|| |
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:
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.
- 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.
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|| |
Described in the early 1960s, retrograde tracheal intubation is an alternative technique for difficult airway management  . However although retrograde tracheal intubation is simple& reliable method in experienced hands  it is not often used , ..
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.
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[Figure 1], [Figure 2], [Figure 3]