Previous article Table of Contents  Next article

LETTER TO EDITOR
Year : 2015  |  Volume : 9  |  Issue : 1  |  Page : 100-101

Successful awake nasal fiberoptic intubation in a patient with restricted mouth opening due to a large tongue flap


Department of Anesthesiology, King Abdulaziz Medical City, P.O. Box 22490, Riyadh, 11426, Saudi Arabia

Correspondence Address:
Dr. Michael O Ayeko
Department of Anesthesiology, King Abdulaziz Medical City, P.O. Box 22490, Riyadh, 11426
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.146330

Rights and Permissions
Date of Web Publication5-Dec-2014
 


How to cite this article:
Ayeko MO, Mohan G, Basha AA. Successful awake nasal fiberoptic intubation in a patient with restricted mouth opening due to a large tongue flap. Saudi J Anaesth 2015;9:100-1

How to cite this URL:
Ayeko MO, Mohan G, Basha AA. Successful awake nasal fiberoptic intubation in a patient with restricted mouth opening due to a large tongue flap. Saudi J Anaesth [serial online] 2015 [cited 2021 Oct 18];9:100-1. Available from: https://www.saudija.org/text.asp?2015/9/1/100/146330

Sir,

Tongue flaps are used to close recurrent palatal fistulas after cleft palate repair. [1] If the tongue flap causes restricted mouth opening, securing the airway before surgery to release the tongue flap can be challenging. [2] We report airway management in a patient with markedly restricted mouth opening due to a tongue flap who was booked for release of the flap.

A 22-year-old female patient, American Society of Anesthesiologists Physical Status 1, was scheduled for release of tongue flap. Airway examination revealed severely restricted mouth opening [Figure 1], thus awake nasotracheal fiber-optic bronchoscope (FOB) intubation was planned. She gave informed consent. Twenty minutes preoperatively, glycopyrrolate 0.2 mg intravenously (IV) was administered. In the operating room, routine noninvasive monitors were applied, and 100% oxygen was administered via face mask. IV dexmedetomidine 0.5 mcg/kg slow bolus, remifentanil IV infusion (0.05-0.25 mcg/kg/min and a total of 2 mg midazolam IV were given for conscious sedation. Xylometazoline 0.1% nasal drops was instilled into both nostrils for vasoconstriction. Topical airway anesthesia was achieved with 4 ml of nebulized 4% lidocaine, 2 puffs of 10% lidocaine into each nostril and spray-as-you-go topical anesthesia with 2% lidocaine. Oxygen at 4 L/min was administered through a nasopharyngeal airway in the right nostril. With the patient sedated, the tip of a well lubricated 5 mm FOB was inserted into the left nostril and a gentle nasendoscopy was performed to define the anatomy. The FOB was then gently advanced in the airspace of the left inferior nasal meatus into the naso/oropharynx and 2 ml of 2% lignocaine was sprayed through the FOB onto the glottis. The tip of the FOB was then advanced through the laryngeal opening into the trachea to just above the carina. Keeping the FOB steady, well lubricated 6.0 'blue-line' nasotracheal tube was gently railroaded over the FOB into the trachea and its correct placement confirmed by the FOB and capnography. General anesthesia was then induced with IV propofol and maintained with sevoflurane in oxygen. The intraoperative course was uneventful and at the end of the operation, the patient was extubated awake uneventfully.
Figure 1: Limited mouth opening

Click here to view


Tongue flaps are widely used for closing residual fistulae of the palate. [1] However, securing the airway before surgery to release the tongue flap can be challenging. [2] Although tongue flaps have been successfully divided under local anesthesia and IV sedation, this requires patient cooperation, and bleeding and aspiration into an unsecured airway may occur. [3] Sahoo et al.[3] described the use of right molar approach with a straight Miller no. 3 blade to achieve oro tracheal intubation under general anesthesia in a patient for tongue flap release. However, they and Eipe et al. [4] concluded that orotracheal fiberoptic intubation is the preferred method for securing the airway because it reduces the risk of trauma to the flap and bleeding into the airway. Although it is advisable to avoid nasal intubation as the palatal flap may be damaged, [5] in our patient we judged that orotracheal fiberoptic intubation would be difficult and may disrupt or damage the flap.

In conclusion, tracheal intubation in patients with restricted mouth opening with a tongue flap is challenging for the anesthesiologist. Although orotacheal intubation is preferred in patients with recent palatoplasty, [5] with markedly restricted mouth opening due to a tongue flap, awake nasotracheal fiberoptic intubation may be necessary.

 
  References Top

1.
Posnick JC, Getz SB Jr. Surgical closure of end-stage palatal fistulas using anteriorly-based dorsal tongue flaps. J Oral Maxillofac Surg 1987;45:907-12.  Back to cited text no. 1
    
2.
Hochberg J, Naidu R, Saunders DE. Anesthesia technique for serving the pedicle of a tongue flap in the presence of a pharyngeal flap. Plast Reconstr Surg 1978;62:905-6.  Back to cited text no. 2
    
3.
Sahoo TK, Ambardekar M, Patel RD, Pandya SH. Airway management in a case of tongue flap division surgery: A case report. Indian J Anaesth 2009;53:75-8.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Eipe N, Pillai AD, Choudhrie A, Choudhrie R. The tongue flap: An iatrogenic difficult airway? Anesth Analg 2006;102:971-3.  Back to cited text no. 4
    
5.
Solan KJ. Nasal intubation and previous cleft palate repair. Anesthesia 2004;59:923-4.  Back to cited text no. 5
    


    Figures

  [Figure 1]



 

Top
 
Previous article    Next article
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  IN THIS Article
   References
   Article Figures

 Article Access Statistics
    Viewed1428    
    Printed17    
    Emailed0    
    PDF Downloaded109    
    Comments [Add]    

Recommend this journal