Dear Editor,
The combination of two airway devices after repeated failure in securing the airway with a single device may accomplish the task of airway securement. We hereby report a 69-year-old woman weighing 45 kg with large left adenocystic maxillary swelling, scheduled for partial left maxillectomy and skull base exploration under general anaesthesia. Computed tomography and magnetic resonance imaging showed a hyperdense mucosal mass [size - 7.2 × 6.8 × 6.4 cm, and extended from mid-lip to the base of tongue], causing narrowing of the oropharynx and deviation of mouth to the right side. We planned to use a fibreoptic bronchoscope (FOB) for airway management. The patient was prepared by giving glycopyrrolate (0.01 mg/kg) intramuscularly and nebulisation with 4% lignocaine 45 min before shifting the patient to the operating room. The nose was prepared with two drops of oxymetazoline hydrochloride 0.05% and lubricated with 2% lignocaine jelly. Subsequently, the patient was given fentanyl 100 µg and midazolam 1mg intravenously 10 min before introducing the fiberscope nasally. Then FOB was introduced with a reinforced endotracheal tube (ETT) primed. Despite multiple attempts and manipulation, we could not visualise any laryngeal structures. The patient had a mouth opening of two finger breadths, so a video laryngoscope (VL) was introduced. Still, with the tumour bulging in the oropharynx, we could not keep the device centrally, and the view was not optimal enough to perform safe intubation (Cormack–Lehane grade II, but the opening was visible at the right extreme upper end). Then the fiberscope was guided by the image from the video laryngoscope, and a 7.0-mm reinforced ETT was successfully inserted.
This case report describes using VL and FOB for difficult airway management. This technique allows the tip of FOB to be manoeuvred under VL guidance.[1] This suggests that failure with a single device should make us consider using a combination of devices.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
We acknowledge Dr. Bibha Kumari, Associate Professor, Department of Anaesthesiology, Indira Gandhi Institute of Medical Sciences, Patna, for giving us the opportunity to do work in this patient.
REFERENCE
- 1.Asai T. Avoiding repeated attempts at tracheal intubation: Can video laryngoscopes be the answer? Anesthesiology. 2016;125:615–7. doi: 10.1097/ALN.0000000000001268. [DOI] [PubMed] [Google Scholar]