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 Table of Contents  
LETTER TO EDITOR
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 141-143

A rare presentation of failed mask ventilation in a postmaxillectomy patient with orbito-oral communication


Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission21-Jun-2021
Date of Acceptance12-Jul-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Aswini Kuberan
Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Post Graduate Medical Education and Research, Dhanvantri Nagar, Gorimedu, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/arwy.arwy_35_21

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How to cite this article:
Kuberan A, Pradeep MS, Dongari S, Rudingwa P. A rare presentation of failed mask ventilation in a postmaxillectomy patient with orbito-oral communication. Airway 2021;4:141-3

How to cite this URL:
Kuberan A, Pradeep MS, Dongari S, Rudingwa P. A rare presentation of failed mask ventilation in a postmaxillectomy patient with orbito-oral communication. Airway [serial online] 2021 [cited 2021 Dec 2];4:141-3. Available from: https://www.arwy.org/text.asp?2021/4/2/141/323579



Airway management in a postoperative case of subtotal maxillectomy with orbital exenteration poses unique anaesthetic challenges during facemask ventilation and intubation. We report a case of a 46-year-old male who underwent left subtotal maxillectomy along with left orbital exenteration for invasive mucormycosis 4 months prior. He was later scheduled for sequestrectomy over the lateral wall of the left orbit. Following subtotal maxillectomy, the patient had a large defect in the hard palate communicating with the left orbit. Due to difficulty in speech and feeding problems, a gel foam pack was placed in situ to seal the defect in the hard palate [Figure 1]a, [Figure 1]b, [Figure 1]c.
Figure 1: Preoperative and intraoperative images of the patient's airway (a) Preoperative mouth opening of patient, (b) Gel foam covering the communication, (c) Orbito-oral communication with left orbital wall slough, (d) computerised tomographic (CT) image of orbital defect, (e) CT image showing absent left maxillary teeth, (f) Transoral endoscopy postintubation depicting defects in soft palate and hard palate, friable orbital wall tissue and endotracheal tube

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Following the preanaesthetic visit, the anaesthesia team anticipated difficulty in mask ventilation and intubation due to a defect in the hard palate that resulted in a communication between the oral cavity and the orbit [Figure 1]d and [Figure 1]e, large tongue and partly edentulous gums. The preoperative plan was a rapid sequence induction and intubation with succinylcholine in view of a potentially difficult airway. After adequate preoxygenation and anaesthetic induction, two-person mask ventilation was attempted and was found difficult despite adequate face mask seal, jaw thrust, placement of an oropharyngeal airway, and high flows of oxygen (15 L/min). Although capnography traces appeared in the initial few breaths, it was completely absent after some time even after the placement of an oropharyngeal airway. It was then that we realised that the gel foam pack had got displaced and an appreciable leak was felt from the left orbital cavity. For 45 s, attempts of ventilation continued with intermittent oxygen flushes. Laryngoscopy attempted with Besdata videolarygoscope (Shenzhen Besdata Technology Co., Ltd) failed because of an anterior larynx (Cormack-Lehane grade 2a), limited space for manipulation of Frova intubating introducer (Cook Critical Care, Letchworth, Hertfordshire, UK) and difficulty in stabilisation of laryngoscope blade due to the partially edentulous gums and hard palate defect. During our second attempt, we successfully intubated the patient using a styletted endotracheal tube with an exaggerated anterior curvature. A transoral endoscopy postintubation revealed defects in soft palate and hard palate, friable orbital wall tissue and endotracheal tube [Figure 1]f. Ventilation attempts with oxygen flushes were continued between the attempts at intubation. There were no episodes of desaturation during intubation attempts and shallow capnography traces appeared during attempts at ventilation.

Very few postoperative cases of partial or total maxillectomies with orbital exenteration, with difficult or failed face mask ventilation during anesthesia induction, are reported in literature.[1],[2] Horishita et al. failed to mask ventilate the patient, due to displacement of ocular adhesive tape. Devys et al. initially failed to mask ventilate, but later succeeded after packing compresses in orbital cavity. We did not attempt to pack the orbit because the mucosa was friable and infected with a possible risk of bleeding. Unlike our case, in scenarios where there was a limited mouth opening, fibreoptic-guided transorbital endotracheal intubation has been attempted.[3] The authors observed that in such cases, transorbital intubation is better than the conventional oral method due to easier alignment of pharyngeal and laryngeal axis with the transorbital axis.[3],[4],[5] We did not attempt transorbital intubation because the orbital mucosa was infected, friable with tendency to bleed and it would interfere with the surgical field. Alternatively, we could have planned for an awake fibreoptic nasal intubation which would have avoided the above undesirable circumstances. Although our team anticipated difficulty in mask ventilation, we did not anticipate displacement of the gel foam packing which further complicated the situation. In such situations, instead of attempting mask ventilation, apnoeic oxygenation using oxygen flow at 15 L/min through a nasal cannula could have been considered as it would have maintained oxygenation while at the same time avoided an increase in intraoral pressure and consequent displacement of the gel foam pack. Based on our experience and review of previous case reports, we would like propose a strategic plan to address similar airway-related issues in the future [Figure 2]. An additional modality that would aid in planning such cases is endoscopy under topical anaesthesia. A transorbital approach to the airway can be planned after discussion with the otorhinolaryngological surgeons regarding the desired operative field and the extent of surgery planned. A transorbital view provides better oro-pharyngo-laryngeal alignment and hence may be a better route for intubation in such cases with orbito-oral communication. The role of imaging modalities and endoscopic studies is of utmost importance for devising an individualised plan for airway management of such cases.
Figure 2: Flow chart depicting action plan for an anticipated difficult airway in postmaxillectomy patients

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Devys JM, Bourdaud N, Baracco P, Plaud B. Orbital exenteration: An unusual cause of failure of assisted ventilation from a face mask. Ann Fr Anesth Reanim 2002;21:224-7.  Back to cited text no. 1
    
2.
Horishita R, Kayashima K. Failed mask ventilation due to air leakage around the orbit in a patient with a history of radical maxillofacial surgery with orbital exenteration. Turk J Anaesthesiol Reanim 2016;44:317-9.  Back to cited text no. 2
    
3.
Waldron NH, Stolp BW, Ogilvie MP, Powers DB, Shaughnessy MR. Transorbital endotracheal intubation: A nonstandard approach to a difficult airway. J Clin Anesth 2016;34:314-7.  Back to cited text no. 3
    
4.
dos Reis Falcão LF, Negreiros F, França RF, Amaral JLG. Unusual access to airway with transorbital intubation. Anesthesiology 2014;121:654.  Back to cited text no. 4
    
5.
Sander M, Lehmann C, Djamchidi C, Haake K, Spies CD, Kox WJ. Fiberoptic transorbital intubation: Alternative for tracheotomy in patients after exenteration of the orbit. Anesthesiology 2002;97:1647.  Back to cited text no. 5
    
6.
Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.  Back to cited text no. 6
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