|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 3 | Page : 358-359
Right molar approach for uvulectomy of secondary non-hodgkins lymphoma of uvula
Akrity Singh1, Rakesh Kumar Singh2
1 Department of Anaesthesiology and Critical Care, IGIMS, Patna, Bihar, India
2 Department of ENT, IGIMS, Patna, Bihar, India
|Date of Web Publication||23-Jun-2014|
Dr. Akrity Singh
A/16, Sri Ram Path, New Punai Chak, Patna - 800 023, Bihar
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh A, Singh RK. Right molar approach for uvulectomy of secondary non-hodgkins lymphoma of uvula. Indian J Anaesth 2014;58:358-9
We appreciate the technique used and successful management of the case by Sharma et al.  and we applied the same for enlarged uvula. Enlarged uvula presents with difficulty in talking, fullness of oropharynx, difficulty in breathing and dysphonia. Neoplasm of uvula is very rare and we present here a case of non-Hodgkins lymphoma secondary to chemo-radiotherapy and anticipated difficult intubation.
A 70 years old female with primary gastric non-Hodgkins Lymphoma was being given chemotherapy at our regional cancer centre. After six cycles of chemotherapy (R-CHOP: Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin and Prednisolone), she developed right extraorbital swelling for which she received radiotherapy. During end course of radiation, she developed enlargement of the uvula for which she visited ENT department. She presented with the complaint of difficulty in deglutition and breathing. On examination uvula was found red, swollen and enlarged. Uvulectomy was planned. Patient and family were explained about the procedure and consent for emergency tracheostomy obtained. Since surgery was elective one, orotracheal intubation was planned as nasotracheal intubation would have caused uvular injury. After instituting routine monitoring, injection glyco-pyrrolate 0.2 mg, injection palonosetron 0.075 mg and injection Fentanyl 50 μg were administered. Induction was effected with injection propofol 2 mg/kg and inj vecuronium bromide 0.1mg/kg was administered. With all precautions and difficult intubation cart ready, intubation was attempted with Portex ® endotracheal tube 7.5 mm ID mounted over stylet through right molar approach avoiding injury to the uvula. A straight blade Miller's laryngoscope was introduced from the right corner of mouth along the groove between the tongue and the tonsil, using leftward and anterior pressure to displace the tongue to the left. The blade was then advanced and its tip made to pass posterior to the epiglottis. Rotation of the neck and manipulation of the cricoid cartilage i.e optimal external laryngeal manipulation (OELM) improved glottic view. After successful endotracheal intubation was confirmed by bilateral chest auscultation and capnography, endotracheal tube was fixed in midline position slowly with the help of Boyle-Davis mouth gag through the opening for tracheal tube [Figure 1]. Surgery and course of anaesthesia were uneventful. Uvula was cut down and cauterisation done. The specimen was sent for histo-pathological examination. The patient was reversed with injection neostigmine and injection glyco-pyrrolate and sent to the ward from where she was discharged on 5 th post operative day.
|Figure 1: showing enlarged uvula fixed in midline with Boyle-davis mouth gag|
Click here to view
The surgical histopathology report confirmed non-Hodgkins Lymphoma. The right molar approach was used by Saxena et al. to tracheal intubation in child with Pierre-Robin syndrome, cleft palate and tongue tie.  Patients presenting with intraoral swelling really pose a difficult laryngoscopy situation, as they physically occupy the oral cavity making glottic visualisation and endotracheal intubation difficult.  Various techniques are available to secure the airway in such situation, like the fibreoptic bronchoscopy (FOB) where intubation is performed under local anaesthesia and is the technique of choice for the management of the anticipated difficult intubation and mask ventilation.  Intubation can be achieved with newer techniques like right molar approach of intubation when FOB is not available. Here, we applied the same to intubate avoiding injury to the uvula and with the help of Boyle-Davis mouth gag, it was fixed in the midline providing space to surgeon and aid in tube fixation as well.
To conclude, lymphomas should be considered in the differential diagnosis of uvular enlargement apart from other causes and right molar approach with Boyle-Davis mouth gag for tube fixation is a possible option for difficult intubation.
| References|| |
|1.||Sharma SB, Nath MP, Pasari C, Chakrabarty A, Choudhury D. Hard palate tumour-A nightmare for the anaesthesiologists: Role of modified molar approach. Indian J Anaesth 2013;57:83-4 |
|2.||Saxena KN, Nischal H, Bhardwaj M. The right molar approach to tracheal intubation in child with Pierre-Robin syndrome, cleft palate and tongue tie. BJA 2008:100;141-2. |
|3.||Potdar M, Patel RD, Dewoolkar LV. Molar intubation for Intra oral swellings: Our Experience. Indian J Anaesth. 2008;52:861. |
|4.||Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004;59:675-94. |