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LETTER TO EDITOR Table of Contents  
Ahead of print publication
Awake fibreoptic intubation in an adult with retrognathia: An anaesthetic challenge


 Department of Anaesthesiology, All India Institute of Medical Science, Patna, Bihar, India

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Date of Submission09-Apr-2022
Date of Acceptance31-May-2022
Date of Web Publication06-Jul-2022
 


How to cite this URL:
Kumar R, Kumari P, Kandrakonda PK, Singh S. Awake fibreoptic intubation in an adult with retrognathia: An anaesthetic challenge. Airway [Epub ahead of print] [cited 2022 Sep 28]. Available from: https://www.arwy.org/preprintarticle.asp?id=350060


Airway management in the presence of retrognathia, micrognathia, mandibular hypoplasia and macroglossia is a challenge to the anaesthesiologist. We present a case of a 29-year-old female admitted for mandibular enhancement with silicone implant placement. She had suffered a traumatic facial injury at the age of 5, for which she was operated twice to relieve the mandibular fusion. On airway examination, interincisor gap was less than two fingers with modified Mallampati Class IV, buck teeth and retrognathia. Computed tomography of the head and neck showed narrowed oropharyngeal airway and a short mandible with relative enlargement of the tongue [Figure 1]. The airway was anaesthetised using 4 mL of 4% lignocaine nebulisation and oxymetazoline drops were instilled in both the nostrils 20 min before shifting to the operating room (OR).
Figure 1: Computed tomography of the head and neck showing narrowed oropharyngeal airway and short mandible with relative enlargement of the tongue

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In the OR, she received intravenous midazolam 1 mg, dexmedetomidine 1 μg/kg bolus infusion over 10 min, followed by an infusion at a rate of 0.3 μg/kg/h. The nasal passage was anaesthetised using two puffs of 10% lignocaine spray. High-flow nasal oxygenation was started with a flow rate of 30 l/min. Awake fibreoptic intubation was attempted twice through the nasal route, but only the epiglottis was visible. She was not cooperating for nasal fibreoptic intubation. She received propofol 2 mg/kg along with sevoflurane 2%–3% concentration in 100% oxygen. We were able to ventilate the patient using a face mask. Fibreoptic intubation was successful on the 3rd attempt after applying jaw thrust along with gentle tongue traction provided by another anaesthesiologist. A 6.5-mm internal diameter endotracheal tube was passed into the trachea under fibreoptic view and confirmed by capnography. Anaesthesia was maintained with sevoflurane in an air-oxygen mixture and intermittent doses of vecuronium. The surgical procedure was uneventful and the rest of the hospital stay was unremarkable.

Fibreoptic intubation is a method of choice in managing the anticipated difficult airway. Awake fibreoptic intubation may become difficult due to altered airway anatomy. The cause of difficult awake fibreoptic intubation in our patient was due to changes in anatomical features such as a receding mandible and a large tongue, resulting in narrowing of the retropharyngeal space. We did not attempt to place a supraglottic device or perform direct laryngoscopy because of a very narrow oropharyngeal space. The anterior larynx is often not aligned with the oral and nasopharyngeal axis because of the large tongue in such cases, creating a difficult airway. Jaw thrust is a common, simple and noninvasive method that is used during fibreoptic intubation. Lingual or tongue traction provides two distinct anatomic advantages in clearing the tongue away from the soft palate and uvula and lifting the epiglottis from the posterior pharyngeal wall. Fibreoptic intubation with lingual traction has a higher success rate when compared to fibreoptic intubation alone in a difficult airway.[1] Lingual traction not only keeps the tongue away from the soft palate and uvula but also lifts the epiglottis away from the posterior pharyngeal wall, thereby helping in improving the success of awake fibreoptic intubation.[2] Cao et al. compared the use of a novel indigenously-designed tongue root holder device for fibreoptic intubation during standard fibreoptic intubation. The mean time for successful first attempt intubation was shorter in the group where the indigenously-designed tongue root holder was used.[3] Thus, lingual traction along with jaw thrust is a valuable adjunct to fibreoptic intubation in patients with anticipated difficult airways as this manoeuvre provides better views of the glottic opening, resulting in greater success during tracheal intubation.[4]

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 identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ching YH, Karlnoski RA, Chen H, Camporesi EM, Shah VV, Padhya TA, et al. Lingual traction to facilitate fiber-optic intubation of difficult airways: A single-anesthesiologist randomized trial. J Anesth 2015;29:263-8.  Back to cited text no. 1
    
2.
Rewari V, Ramachandran R, Trikha A. Lingual traction: A useful manoeuvre to lift the epiglottis in a difficult oral fibreoptic intubation. Acta Anaesthesiol Scand 2009;53:695-6.  Back to cited text no. 2
    
3.
Cao X, Wu J, Fang Y, Ding Z, Qi T. A new self-designed “tongue root holder” device to aid fiberoptic intubation. Clin Oral Investig 2020;24:4335-42.  Back to cited text no. 3
    
4.
Mangar D, Ching YH, Shah VV, Camporesi EM. Lingual traction to facilitate fibreoptic intubation in patients with difficult airways under general anesthesia. Can J Anaesth 2014;61:889-90.  Back to cited text no. 4
    

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Correspondence Address:
Rajnish Kumar,
Department of Anaesthesiology, All India Institute of Medical Science, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None



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