Letters to Editor Page | 222
should be considered complementary rather than an alternative to one another as their combined usage is associated with USG reduced radiation exposure, USG ability to conduct procedure in unusual patient positions, Fluoro identifying correct needle insertion depth; contrast spread as well as ruling out intravascular [Figure 2] or intrathecal contrast spread. In an era of increasing consumerism, peer and medico-legal scrutiny, multimodal imaging protocol may prove to be a safer alternative compared to the traditional practice of unimodal guided pain interventions. Mayank Gupta, Priyanka Gupta1 Medical Intensive Care Unit, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, 1Department of Anaesthesia, ESI Hospital, Okhla, New Delhi, India Address for correspondence: Dr. Mayank Gupta, 14, Himvihar Apartment, Plot No. 8, I.P. Extension, New Delhi - 110 092, India. E-mail: [email protected]
REFERENCES 1. Manchikanti L, Cash KA, Pampati V, McManus CD, Damron KS. Evaluation of fluoroscopically guided caudal epidural injections. Pain Physician 2004;7:81-92. 2. Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, et al. Epidural steroids in the management of chronic spinal pain: A systematic review. Pain Physician 2007;10:185-212. 3. Renfrew DL, Moore TE, Kathol MH, el-Khoury GY, Lemke JH, Walker CW. Correct placement of epidural steroid injections: Fluoroscopic guidance and contrast administration. AJNR Am J Neuroradiol 1991;12:1003-7. 4. Price CM, Rogers PD, Prosser AS, Arden NK. Comparison of the caudal and lumbar approaches to the epidural space. Ann Rheum Dis 2000;59:879-82. 5. Klocke R, Jenkinson T, Glew D. Sonographically guided caudal epidural steroid injections. J Ultrasound Med 2003;22:1229-32. Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.152895
Retromolar intubation: A better alternative to submental intubation or tracheostomy for dental occlusion by intermaxillary fixation Sir, Patients with complex maxillofacial trauma requiring intraoperative restoration of dental occlusion by intermaxillary fixation (IMF), pose a great challenge even for experienced anesthesiologists. In most situations, airway management using oral endotracheal tube (ETT) is potentially ruled out.[1] We report a case of a 31-yearold male with panfacial trauma (bilateral maxillary, right mandibular and nasal bone fractures) posted for open reduction and internal fixation (ORIF) of multiple fractures, where we managed to secure the airway by oral intubation with a regular polyvinyl chloride (PVC) ETT and provided occlusion by using the retromolar space for tube placement. We ruled out various methods of airway management like nasotracheal intubation, which is traumatic, contraindicated in nasal or base of skull fractures and cerebrospinal fluid leak. Though tracheostomy provides a secure airway and nil surgical Vol. 9, Issue 2, April-June 2015
interference, it was not considered as it is invasive and associated with subglottic stenosis, injury to lingual nerve/esophagus, speech and swallowing difficulties.[2] Submental intubation avoids the need for short term tracheostomy. [3] However, it is associated with orocutaneous fistula, injury to sublingual/submandibular gland, hypertrophic scarring and infection.[2] We used standard general anesthesia technique and intubated the patient with an oral PVC tube of 8 mm ID [Figure 1]. It was then grasped with gloved fingers and passed into the retromolar space.[4] ETT was fixed with elastic plaster at the angle of the mouth. Dental occlusion required for the procedure was achieved with no noticeable changes in airway pressures or visible tube kinking [Figures 2 and 3]. After ORIF had been completed, the temporary occlusion was released. At the end of the procedure, patient was extubated and shifted to the postoperative ward. Saudi Journal of Anesthesia
Letters to Editor
Figure 1: Retromolar intubation without dental occlusion
The retromolar space is a potential space for ETT placement bounded anteriorly by the last molar and posteriorly by the anterior edge of ascending ramus of mandible. Adequacy of this space can be confirmed by placing finger behind the distal molar.[5] Unlike the technique described by Malhotra et al., the need of a flexometallic tube and fixation by wire ligature in a figure of eight patterns is not always necessary as seen in our patient if the space is adequate. Hence, it is a feasible alternative to the invasive methods described above, cheaper, associated with fewer complications and less timeconsuming.[2] However, when the space is insufficient due to impacted/erupting third molar, its use may be limited.[6] Martinez et al., described that the erupting/impacted tooth can be extracted before performing a semi lunar (180°) osteotomy.[4] However, this technique is associated with destruction of bony anatomy. Space consumed by oral ETT can interfere with the application of dental fixation devices, and surgical field can be compromised, especially in cases of bilateral maxillary/mandibular fractures.[7] Furthermore, the efficacy of retromolar intubation in patients with preexisting temporomandibular dysfunction and its use for long-term postoperative use is doubtful.[8] Despite these limitations, retromolar intubation can be considered an excellent alternative when temporary dental occlusion by IMF is required as it rules out the need for invasive airway management and complications related to them. Madhu Rao, Deviprasad Shetty1, Kush A. Goyal, Kanika P. Nanda2 Departments of Anaesthesiology and 1General Surgery, Kasturba Medical College, 2Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal, Karnataka, India
Figure 2: Retromolar intubation with dental occlusion
Address for correspondence: Dr. Kush Ashokkumar Goyal, Department of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India. E-mail: [email protected]
REFERENCES
Figure 3: Ventilator monitor screen showing normal peak airway pressure
Saudi Journal of Anesthesia
1. Caron G, Paquin R, Lessard MR, Trepanier CA, Landry PE. Submental endotracheal intubation: An alternative to tracheostomy in patients with midfacial and panfacial fractures. J Trauma 2000;46:400-2. 2. Lokesh U, Sudarshan, Jannu A, Bhattacharya D. Retromolar intubation: An alternative non invasive technique for airway management in maxillofacial trauma. Arch CranOroFac Sci 2013;1:22-5. 3. Caron G, Paquin R, Lessard MR, Trépanier CA, Landry PE. Submental endotracheal intubation: An alternative to tracheotomy in patients with midfacial and panfacial fractures. J Trauma 2000;48:235-40. 4. Martinez-Lage JL, Eslava JM, Cebrecos AI, Marcos O. Retromolar intubation. J Oral Maxillofac Surg 1998; 56:302-5. 5. Lee SS, Huang SH, Wu SH, Sun IF, Chu KS, Lai CS, et al. A review of intraoperative airway management for midface facial bone fracture patients. Ann Plast Surg 2009;63:162-6.
Vol. 9, Issue 2, April-June 2015
Page | 223
Page | 224
6. Burkle CM, Walsh MT, Harrison BA, Curry TB, Rose SH. Airway management after failure to intubate by direct laryngoscopy: Outcomes in a large teaching hospital. Can J Anaesth 2005;52:634-40. 7. Malhotra N. Retromolar intubation: A technical note. Indian J Anaesth 2005;49:467-8. 8. Dutta A, Kumar V, Saha SS, Sood J, Khazanchi RK. Retromolar tracheal tube positioning for patients undergoing faciomaxillary surgery. Can J Anaesth 2005;52:341.
Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.152896
Ultrasound out of plane approach for pulsed radiofrequency treatment of post herniorrhaphy pain: Synchronizing treatment and imaging modality Sir, Chronic postherniorrhaphy pain is a debilitating complication resulting from surgical trauma or ilioinguinaliliohypogastric (ILIH) nerve entrapment from sutures, autoclips or mesh.[1-3] A 55-year-old male presented with severe continuous right sided groin pain radiating to superiomedial thigh that developed immediately following right laparoscopic total extra-peritoneal herniorrhaphy 2 years ago followed by mesh removal for the same with no pain relief. The pain intensity was 8/10 with a past 4 weeks maximum and average of 10/10 and 8/10 respectively on 11 point numerical rating scale (NRS). The pain was electric shock-like, burning and numbness in quality with the pain detect tool score of 20. The aggravating factors were standing, walking, touching, pressing and wearing clothes while there were no relieving factors. It interfered with every inclusive of social, occupational and emotional aspect of patient’s life. On examination, allodynia and Tinel’s sign was positive. The pain was poorly controlled on tablet pregabalin 450 mg, duloxetine 40 mg, acetaminophen 3 g., tramadol 300 mg daily along with fentanyl 50 µg/h transdermal patch. The patient underwent ultrasound (USG) guided ILIH diagnostic block with 3 ml of 0.5% resulting in 80% pain relief lasting for 120 min. A linear transducer (5-12 MHz) with out of plane approach was employed for accurate neural identification, needle placement and removing the technical bias/error by employing the same imaging approach during both diagnostic and therapeutic blocks. USG guided ILIH pulsed radiofrequency (PRF) Vol. 9, Issue 2, April-June 2015
was performed the next day by placing a linear transducer probe diagonally along a line joining anterior superior iliac spine (ASIS) and umbilicus with its lateral part resting upon the ASIS. The ILIH nerves were visualized as two hyper echoic shadows in the fascial plane between internal oblique and transversus abdominis from outside-in. A 10 cm radio frequency needle with 5 mm uninsulated tip was advanced in out of plane approach to reach Ilioinguinal and then iliohypogastric nerve medial to it. The patient complained of concordant pain and sensations upon sensory stimulation at 50 Hz and 0.5 V. The PRF was carried at 42°C for 360 min which was associated with a reduction in NRS from 8 to 1 at 1-month follow-up. The patient’s medications were gradually tapered, and patient was pain-free off medications at 3 months follow-up postprocedure. The intermittent application of highfrequency electrical current during PRF allows dissipation of heat restricting the maximum temperature to 42°C; hence avoiding neurodestruction and postprocedure neuritis.[4] The electromagnetic field, the neuromodulatory working force of PRF is densest at the electrode tip.[5] Therefore, it is recommended to place the electrode tip perpendicular to the target nerve.[5] An out of plane imaging approach for needle placement falls in sync with this unique mechanism of action of PRF placing its tip in the requisite orientation. Advancements till now have allowed use of USG guidance for peripheral nerve blocks to be practiced as a norm. Adapting and synchronizing the imaging approach with the treatment modality being used is a much-needed next step ahead in the field of USG guided interventional pain medicine. To conclude PRF Saudi Journal of Anesthesia
Copyright of Saudi Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
should be considered complementary rather than an alternative to one another as their combined usage is associated with USG reduced radiation exposure, USG ability to conduct procedure in unusual patient positions, Fluoro identifying correct needle insertion depth; contrast spread as well as ruling out intravascular [Figure 2] or intrathecal contrast spread. In an era of increasing consumerism, peer and medico-legal scrutiny, multimodal imaging protocol may prove to be a safer alternative compared to the traditional practice of unimodal guided pain interventions. Mayank Gupta, Priyanka Gupta1 Medical Intensive Care Unit, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, 1Department of Anaesthesia, ESI Hospital, Okhla, New Delhi, India Address for correspondence: Dr. Mayank Gupta, 14, Himvihar Apartment, Plot No. 8, I.P. Extension, New Delhi - 110 092, India. E-mail: [email protected]
REFERENCES 1. Manchikanti L, Cash KA, Pampati V, McManus CD, Damron KS. Evaluation of fluoroscopically guided caudal epidural injections. Pain Physician 2004;7:81-92. 2. Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, et al. Epidural steroids in the management of chronic spinal pain: A systematic review. Pain Physician 2007;10:185-212. 3. Renfrew DL, Moore TE, Kathol MH, el-Khoury GY, Lemke JH, Walker CW. Correct placement of epidural steroid injections: Fluoroscopic guidance and contrast administration. AJNR Am J Neuroradiol 1991;12:1003-7. 4. Price CM, Rogers PD, Prosser AS, Arden NK. Comparison of the caudal and lumbar approaches to the epidural space. Ann Rheum Dis 2000;59:879-82. 5. Klocke R, Jenkinson T, Glew D. Sonographically guided caudal epidural steroid injections. J Ultrasound Med 2003;22:1229-32. Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.152895
Retromolar intubation: A better alternative to submental intubation or tracheostomy for dental occlusion by intermaxillary fixation Sir, Patients with complex maxillofacial trauma requiring intraoperative restoration of dental occlusion by intermaxillary fixation (IMF), pose a great challenge even for experienced anesthesiologists. In most situations, airway management using oral endotracheal tube (ETT) is potentially ruled out.[1] We report a case of a 31-yearold male with panfacial trauma (bilateral maxillary, right mandibular and nasal bone fractures) posted for open reduction and internal fixation (ORIF) of multiple fractures, where we managed to secure the airway by oral intubation with a regular polyvinyl chloride (PVC) ETT and provided occlusion by using the retromolar space for tube placement. We ruled out various methods of airway management like nasotracheal intubation, which is traumatic, contraindicated in nasal or base of skull fractures and cerebrospinal fluid leak. Though tracheostomy provides a secure airway and nil surgical Vol. 9, Issue 2, April-June 2015
interference, it was not considered as it is invasive and associated with subglottic stenosis, injury to lingual nerve/esophagus, speech and swallowing difficulties.[2] Submental intubation avoids the need for short term tracheostomy. [3] However, it is associated with orocutaneous fistula, injury to sublingual/submandibular gland, hypertrophic scarring and infection.[2] We used standard general anesthesia technique and intubated the patient with an oral PVC tube of 8 mm ID [Figure 1]. It was then grasped with gloved fingers and passed into the retromolar space.[4] ETT was fixed with elastic plaster at the angle of the mouth. Dental occlusion required for the procedure was achieved with no noticeable changes in airway pressures or visible tube kinking [Figures 2 and 3]. After ORIF had been completed, the temporary occlusion was released. At the end of the procedure, patient was extubated and shifted to the postoperative ward. Saudi Journal of Anesthesia
Letters to Editor
Figure 1: Retromolar intubation without dental occlusion
The retromolar space is a potential space for ETT placement bounded anteriorly by the last molar and posteriorly by the anterior edge of ascending ramus of mandible. Adequacy of this space can be confirmed by placing finger behind the distal molar.[5] Unlike the technique described by Malhotra et al., the need of a flexometallic tube and fixation by wire ligature in a figure of eight patterns is not always necessary as seen in our patient if the space is adequate. Hence, it is a feasible alternative to the invasive methods described above, cheaper, associated with fewer complications and less timeconsuming.[2] However, when the space is insufficient due to impacted/erupting third molar, its use may be limited.[6] Martinez et al., described that the erupting/impacted tooth can be extracted before performing a semi lunar (180°) osteotomy.[4] However, this technique is associated with destruction of bony anatomy. Space consumed by oral ETT can interfere with the application of dental fixation devices, and surgical field can be compromised, especially in cases of bilateral maxillary/mandibular fractures.[7] Furthermore, the efficacy of retromolar intubation in patients with preexisting temporomandibular dysfunction and its use for long-term postoperative use is doubtful.[8] Despite these limitations, retromolar intubation can be considered an excellent alternative when temporary dental occlusion by IMF is required as it rules out the need for invasive airway management and complications related to them. Madhu Rao, Deviprasad Shetty1, Kush A. Goyal, Kanika P. Nanda2 Departments of Anaesthesiology and 1General Surgery, Kasturba Medical College, 2Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal, Karnataka, India
Figure 2: Retromolar intubation with dental occlusion
Address for correspondence: Dr. Kush Ashokkumar Goyal, Department of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India. E-mail: [email protected]
REFERENCES
Figure 3: Ventilator monitor screen showing normal peak airway pressure
Saudi Journal of Anesthesia
1. Caron G, Paquin R, Lessard MR, Trepanier CA, Landry PE. Submental endotracheal intubation: An alternative to tracheostomy in patients with midfacial and panfacial fractures. J Trauma 2000;46:400-2. 2. Lokesh U, Sudarshan, Jannu A, Bhattacharya D. Retromolar intubation: An alternative non invasive technique for airway management in maxillofacial trauma. Arch CranOroFac Sci 2013;1:22-5. 3. Caron G, Paquin R, Lessard MR, Trépanier CA, Landry PE. Submental endotracheal intubation: An alternative to tracheotomy in patients with midfacial and panfacial fractures. J Trauma 2000;48:235-40. 4. Martinez-Lage JL, Eslava JM, Cebrecos AI, Marcos O. Retromolar intubation. J Oral Maxillofac Surg 1998; 56:302-5. 5. Lee SS, Huang SH, Wu SH, Sun IF, Chu KS, Lai CS, et al. A review of intraoperative airway management for midface facial bone fracture patients. Ann Plast Surg 2009;63:162-6.
Vol. 9, Issue 2, April-June 2015
Page | 223
Page | 224
6. Burkle CM, Walsh MT, Harrison BA, Curry TB, Rose SH. Airway management after failure to intubate by direct laryngoscopy: Outcomes in a large teaching hospital. Can J Anaesth 2005;52:634-40. 7. Malhotra N. Retromolar intubation: A technical note. Indian J Anaesth 2005;49:467-8. 8. Dutta A, Kumar V, Saha SS, Sood J, Khazanchi RK. Retromolar tracheal tube positioning for patients undergoing faciomaxillary surgery. Can J Anaesth 2005;52:341.
Access this article online Quick Response Code:
Website: www.saudija.org
DOI: 10.4103/1658-354X.152896
Ultrasound out of plane approach for pulsed radiofrequency treatment of post herniorrhaphy pain: Synchronizing treatment and imaging modality Sir, Chronic postherniorrhaphy pain is a debilitating complication resulting from surgical trauma or ilioinguinaliliohypogastric (ILIH) nerve entrapment from sutures, autoclips or mesh.[1-3] A 55-year-old male presented with severe continuous right sided groin pain radiating to superiomedial thigh that developed immediately following right laparoscopic total extra-peritoneal herniorrhaphy 2 years ago followed by mesh removal for the same with no pain relief. The pain intensity was 8/10 with a past 4 weeks maximum and average of 10/10 and 8/10 respectively on 11 point numerical rating scale (NRS). The pain was electric shock-like, burning and numbness in quality with the pain detect tool score of 20. The aggravating factors were standing, walking, touching, pressing and wearing clothes while there were no relieving factors. It interfered with every inclusive of social, occupational and emotional aspect of patient’s life. On examination, allodynia and Tinel’s sign was positive. The pain was poorly controlled on tablet pregabalin 450 mg, duloxetine 40 mg, acetaminophen 3 g., tramadol 300 mg daily along with fentanyl 50 µg/h transdermal patch. The patient underwent ultrasound (USG) guided ILIH diagnostic block with 3 ml of 0.5% resulting in 80% pain relief lasting for 120 min. A linear transducer (5-12 MHz) with out of plane approach was employed for accurate neural identification, needle placement and removing the technical bias/error by employing the same imaging approach during both diagnostic and therapeutic blocks. USG guided ILIH pulsed radiofrequency (PRF) Vol. 9, Issue 2, April-June 2015
was performed the next day by placing a linear transducer probe diagonally along a line joining anterior superior iliac spine (ASIS) and umbilicus with its lateral part resting upon the ASIS. The ILIH nerves were visualized as two hyper echoic shadows in the fascial plane between internal oblique and transversus abdominis from outside-in. A 10 cm radio frequency needle with 5 mm uninsulated tip was advanced in out of plane approach to reach Ilioinguinal and then iliohypogastric nerve medial to it. The patient complained of concordant pain and sensations upon sensory stimulation at 50 Hz and 0.5 V. The PRF was carried at 42°C for 360 min which was associated with a reduction in NRS from 8 to 1 at 1-month follow-up. The patient’s medications were gradually tapered, and patient was pain-free off medications at 3 months follow-up postprocedure. The intermittent application of highfrequency electrical current during PRF allows dissipation of heat restricting the maximum temperature to 42°C; hence avoiding neurodestruction and postprocedure neuritis.[4] The electromagnetic field, the neuromodulatory working force of PRF is densest at the electrode tip.[5] Therefore, it is recommended to place the electrode tip perpendicular to the target nerve.[5] An out of plane imaging approach for needle placement falls in sync with this unique mechanism of action of PRF placing its tip in the requisite orientation. Advancements till now have allowed use of USG guidance for peripheral nerve blocks to be practiced as a norm. Adapting and synchronizing the imaging approach with the treatment modality being used is a much-needed next step ahead in the field of USG guided interventional pain medicine. To conclude PRF Saudi Journal of Anesthesia
Copyright of Saudi Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
