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COMMENTS ON PUBLISHED ARTICLE
Year : 2014  |  Volume : 58  |  Issue : 1  |  Page : 101-102  

Difficult mask ventilation due to a large oral tumour


Department of Anaesthesia, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Date of Web Publication13-Feb-2014

Correspondence Address:
Neeraj Kumar
Manvi Home Ahead Shyamal Hospital, Urjagram, Khazpura, Patna - 800 014, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.126856

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How to cite this article:
Kumar S, Kumar N. Difficult mask ventilation due to a large oral tumour. Indian J Anaesth 2014;58:101-2

How to cite this URL:
Kumar S, Kumar N. Difficult mask ventilation due to a large oral tumour. Indian J Anaesth [serial online] 2014 [cited 2020 Oct 22];58:101-2. Available from: https://www.ijaweb.org/text.asp?2014/58/1/101/126856

Sir,

The article by Sreeramalu et al. made for interesting reading. [1] We agree with their conclusion that managing each case of predicted difficult ventilation is highly individualized. We present a case of anticipated Han's grade 3 mask ventilation [2] where improvisation for induction and a blind nasal technique for intubation were used.

A 75-year-old male of 52 kg body weight was posted for excision of oral tumour under general anaesthesia. His physical examination was unremarkable and routine haematological investigations were within normal limits. The airway [Figure 1] showed a massive, friable tumour obstructing the oral cavity which bled on touch. Airway examination showed normal mento-hyoid and mento-thyroid distances but Mallampati grading and upper lip bite test could not be assessed due large oral tumour. Both the nostrils appeared normal. A computed tomography scan revealed that the tumour was not obstructing the nasopharynx or the oropharynx posteriorly and was confined to the anterior part of the oral cavity. It was decided to use a paediatric mask that could cover the nose for induction of anaesthesia. A blind nasal intubation under general anaesthesia with spontaneous ventilation was planned as the passage of the nasotracheal tube appeared safe on computed tomography scan. Written informed consent was obtained to perform an emergency tracheostomy if needed. Nasal passage was decongested with 0.1% xylometazoline nasal drops.
Figure 1: A large friable oral tumour

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After instituting routine monitoring in the form of ECG, NIBP and pulse oximetery, fentanyl 2 μg/kg and propofol 2 mg/kg in increments were administered intravenously. A paediatric face mask that could cover the nose was used for administering halothane 2-3% in oxygen keeping an eye on ventilation. It was found after a few minutes that ventilation could be assisted gently through this mask. A 7.5 mm ID cuffed endotracheal tube was well lubricated with 2% lignocaine jelly and was introduced into the right nostril. The adaptor of a side stream capnograph was attached to the tracheal tube connector and the capnogram was used for help in proper placement of the tracheal tube during this blind nasal intubation. The tracheal cuff was inflated and tube placement was confirmed by bilateral chest auscultation. Vecuronium was administered for neuromuscular blockade. The course of surgery and anaesthesia remained uneventful.

This case highlights the fact that in absence of fibre optic bronchoscope, radiological support remains our best ally in assessment and management of difficult airways. In the absence of fibre optic bronchoscope, another option in our patient was retrograde intubation. It was decided to avoid it as the tumour was too friable and we feared excessive haemorrhage in case of inadvertent tumour injury by the guide wire during the attempt.

We relied on the age old technique of blind nasal intubation that proved to be safe as per our assessment based on computed tomography scan. Each case is unique, as described by Sreeramalu et al. and no technique is obsolete in managing these problems where modern aids are not available.

 
   References Top

1.Sreeramalu SK, Sumalatha GB, Dodawad RR, Prabhu JP. Fibrodysplasia of maxilla: A difficult airway. Indian J Anaesth 2013;57:300-2.  Back to cited text no. 1
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2.Han R, Tremper KK, Kheterpal S, O'Reilly M. Grading scale for mask ventilation. Anesthesiology 2004;101:267.  Back to cited text no. 2
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