Letters to Editor using an NIM EMG ETT with previously undiagnosed tracheomalacia. Case Rep Anesthesiol 2013;2013:568373. 3. Lim H, Kim JH, Kim D, Lee J, Son JS, Kim DC, et al. Tracheal rupture after endotracheal intubation: A report of three cases. Korean J Anesthesiol 2012;62:277‑80. 4. Kim KH, Kim MH, Choi JB, Kuh JH, Jo JK, Park HK. Postintubation tracheal ruptures: A case report. Korean J Thorac Cardiovasc Surg 2011;44:260‑5. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.135092
Right molar approach for uvulectomy of secondary non‑hodgkins lymphoma of uvula Sir, We appreciate the technique used and successful management of the case by Sharma et al.[1] and we applied the same for enlarged uvula. Enlarged uvula presents with difficulty in talking, fullness of oropharynx, difficulty in breathing and dysphonia. Neoplasm of uvula is very rare and we present here a case of non‑Hodgkins lymphoma secondary to chemo‑radiotherapy and anticipated difficult intubation. A 70 years old female with primary gastric non‑Hodgkins Lymphoma was being given chemotherapy at our regional cancer centre. After six cycles of chemotherapy (R‑CHOP: Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin and Prednisolone), she developed right extraorbital swelling for which she received radiotherapy. During end course of radiation, she developed enlargement of the uvula for which she visited ENT department. She presented with the complaint of difficulty in deglutition and breathing. On examination uvula was found red, swollen and enlarged. Uvulectomy was planned. Patient and family were explained about the procedure and consent for emergency tracheostomy obtained. Since surgery was elective one, orotracheal intubation was planned as nasotracheal intubation would have caused uvular injury. After instituting 358
routine monitoring, injection glyco‑pyrrolate 0.2 mg, injection palonosetron 0.075 mg and injection Fentanyl 50 µg were administered. Induction was effected with injection propofol 2 mg/kg and inj vecuronium bromide 0.1mg/kg was administered. With all precautions and difficult intubation cart ready, intubation was attempted with Portex®endotracheal tube 7.5 mm ID mounted over stylet through right molar approach avoiding injury to the uvula. A straight blade Miller’s laryngoscope was introduced from the right corner of mouth along the groove between the tongue and the tonsil, using leftward and anterior pressure to displace the tongue to the left. The blade was then advanced and its tip made to pass posterior to the epiglottis. Rotation of the neck and manipulation of the cricoid cartilage i.e optimal external laryngeal manipulation (OELM) improved glottic view. After successful endotracheal intubation was confirmed by bilateral chest auscultation and capnography, endotracheal tube was fixed in midline position slowly with the help of Boyle-Davis mouth gag through the opening for tracheal tube [Figure 1]. Surgery and course of anaesthesia were uneventful. Uvula was cut down and cauterisation done. The specimen was sent for histo‑pathological examination. The patient was reversed with injection neostigmine and injection glyco‑pyrrolate and sent to the ward from where she was discharged on 5th post operative day. The surgical histopathology report confirmed non‑Hodgkins Lymphoma. The right molar approach was used by Saxena et al. to tracheal intubation in child with Pierre‑Robin syndrome, cleft palate and tongue tie.[2] Patients presenting with intraoral swelling really pose a difficult laryngoscopy
Figure 1: showing enlarged uvula fixed in midline with Boyle-davis mouth gag Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014
Letters to Editor
situation, as they physically occupy the oral cavity making glottic visualisation and endotracheal intubation difficult.[3] Various techniques are available to secure the airway in such situation, like the fibreoptic bronchoscopy (FOB) where intubation is performed under local anaesthesia and is the technique of choice for the management of the anticipated difficult intubation and mask ventilation. [4] Intubation can be achieved with newer techniques like right molar approach of intubation when FOB is not available. Here, we applied the same to intubate avoiding injury to the uvula and with the help of Boyle‑Davis mouth gag, it was fixed in the midline providing space to surgeon and aid in tube fixation as well. To conclude, lymphomas should be considered in the differential diagnosis of uvular enlargement apart from other causes and right molar approach with Boyle‑Davis mouth gag for tube fixation is a possible option for difficult intubation.
Akrity Singh, Rakesh Kumar Singh1 Department of Anaesthesiology and Critical Care and 1ENT, IGIMS, Patna, Bihar, India Address for correspondence: Dr. Akrity Singh, A/16, Sri Ram Path, New Punai Chak, Patna - 800 023, Bihar, India. E-mail: [email protected]
References 1.
Sharma SB, Nath MP, Pasari C, Chakrabarty A, Choudhury D. Hard palate tumour‑A nightmare for the anaesthesiologists: Role of modified molar approach. Indian J Anaesth 2013;57:83‑4 2. Saxena KN, Nischal H, Bhardwaj M. The right molar approach to tracheal intubation in child with Pierre‑Robin syndrome, cleft palate and tongue tie. BJA 2008:100;141‑2. 3. Potdar M, Patel RD, Dewoolkar LV. Molar intubation for Intra oral swellings: Our Experience. Indian J Anaesth. 2008;52:861. 4. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59:675-94. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.135094
Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014
A patient with acute abducens nerve palsy for lower segment caesarean section Sir, A full term 32‑year‑old parturient with Gradenigo’s syndrome was scheduled for a lower segment caesarean section (LSCS). She had isolated left abducens nerve (AN) palsy due to apical petrositis diagnosed on magnetic resonance imaging. She had complaints of severe headache on and off associated with vomiting for 7 days and diplopia involving left eye for 4 days. She was haemodynamically stable and pregnancy induced hypertension was ruled out. She was on systemic antibiotics and acetaminophen 650 mg 8th hourly and had received counselling about the disease. Elective LSCS was planned as it was precious pregnancy for the couple. On preanaesthesia check‑up, she was found to have no other systemic illness and no contraindication for regional anaesthesia. Her coagulation parameters were normal. Her routine investigations (complete blood picture, urea, creatinine, and serum electrolytes) were within the normal limits. Surgery was completed under general anaesthesia with Sellick’s manoeuvre, using thiopentone, succinylcholine, and oxygen, nitrous oxide, fentanyl, and vecuronium maintenance on controlled ventilation. She improved clinically after 5 weeks. Gradenigo’s syndrome comprises a triad of suppurative otitis media, pain along distribution of trigeminal nerve and AN palsy. The causes are apical petrosis due to suppurative otitis media and extradural inflammation at petrous apex involving trigeminal ganglion and AN. If untreated, it can lead to meningitis, intracranial abscess, prevertebral/parapharyngeal abscess, spread to sympathetic plexus and involve IX, X, XI cranial nerves (CNs) (Vernett’s syndrome).[1] All CNs, with the exception of I, IX, X can be affected following dural puncture. VI CN palsy is more common owing to its long intracranial course, which leads to traction and stretching of the nerve due to cerebrospinal fluid loss. Cain et al. conducted a systematic literature review of AN palsy due to dural puncture and found that there were 28 patients with temporary and permanent AN palsy (a total of 17 case reports and 5 case series).[2] The procedures, which 359
Copyright of Indian 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.
DOI: 10.4103/0019-5049.135092
Right molar approach for uvulectomy of secondary non‑hodgkins lymphoma of uvula Sir, We appreciate the technique used and successful management of the case by Sharma et al.[1] and we applied the same for enlarged uvula. Enlarged uvula presents with difficulty in talking, fullness of oropharynx, difficulty in breathing and dysphonia. Neoplasm of uvula is very rare and we present here a case of non‑Hodgkins lymphoma secondary to chemo‑radiotherapy and anticipated difficult intubation. A 70 years old female with primary gastric non‑Hodgkins Lymphoma was being given chemotherapy at our regional cancer centre. After six cycles of chemotherapy (R‑CHOP: Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin and Prednisolone), she developed right extraorbital swelling for which she received radiotherapy. During end course of radiation, she developed enlargement of the uvula for which she visited ENT department. She presented with the complaint of difficulty in deglutition and breathing. On examination uvula was found red, swollen and enlarged. Uvulectomy was planned. Patient and family were explained about the procedure and consent for emergency tracheostomy obtained. Since surgery was elective one, orotracheal intubation was planned as nasotracheal intubation would have caused uvular injury. After instituting 358
routine monitoring, injection glyco‑pyrrolate 0.2 mg, injection palonosetron 0.075 mg and injection Fentanyl 50 µg were administered. Induction was effected with injection propofol 2 mg/kg and inj vecuronium bromide 0.1mg/kg was administered. With all precautions and difficult intubation cart ready, intubation was attempted with Portex®endotracheal tube 7.5 mm ID mounted over stylet through right molar approach avoiding injury to the uvula. A straight blade Miller’s laryngoscope was introduced from the right corner of mouth along the groove between the tongue and the tonsil, using leftward and anterior pressure to displace the tongue to the left. The blade was then advanced and its tip made to pass posterior to the epiglottis. Rotation of the neck and manipulation of the cricoid cartilage i.e optimal external laryngeal manipulation (OELM) improved glottic view. After successful endotracheal intubation was confirmed by bilateral chest auscultation and capnography, endotracheal tube was fixed in midline position slowly with the help of Boyle-Davis mouth gag through the opening for tracheal tube [Figure 1]. Surgery and course of anaesthesia were uneventful. Uvula was cut down and cauterisation done. The specimen was sent for histo‑pathological examination. The patient was reversed with injection neostigmine and injection glyco‑pyrrolate and sent to the ward from where she was discharged on 5th post operative day. The surgical histopathology report confirmed non‑Hodgkins Lymphoma. The right molar approach was used by Saxena et al. to tracheal intubation in child with Pierre‑Robin syndrome, cleft palate and tongue tie.[2] Patients presenting with intraoral swelling really pose a difficult laryngoscopy
Figure 1: showing enlarged uvula fixed in midline with Boyle-davis mouth gag Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014
Letters to Editor
situation, as they physically occupy the oral cavity making glottic visualisation and endotracheal intubation difficult.[3] Various techniques are available to secure the airway in such situation, like the fibreoptic bronchoscopy (FOB) where intubation is performed under local anaesthesia and is the technique of choice for the management of the anticipated difficult intubation and mask ventilation. [4] Intubation can be achieved with newer techniques like right molar approach of intubation when FOB is not available. Here, we applied the same to intubate avoiding injury to the uvula and with the help of Boyle‑Davis mouth gag, it was fixed in the midline providing space to surgeon and aid in tube fixation as well. To conclude, lymphomas should be considered in the differential diagnosis of uvular enlargement apart from other causes and right molar approach with Boyle‑Davis mouth gag for tube fixation is a possible option for difficult intubation.
Akrity Singh, Rakesh Kumar Singh1 Department of Anaesthesiology and Critical Care and 1ENT, IGIMS, Patna, Bihar, India Address for correspondence: Dr. Akrity Singh, A/16, Sri Ram Path, New Punai Chak, Patna - 800 023, Bihar, India. E-mail: [email protected]
References 1.
Sharma SB, Nath MP, Pasari C, Chakrabarty A, Choudhury D. Hard palate tumour‑A nightmare for the anaesthesiologists: Role of modified molar approach. Indian J Anaesth 2013;57:83‑4 2. Saxena KN, Nischal H, Bhardwaj M. The right molar approach to tracheal intubation in child with Pierre‑Robin syndrome, cleft palate and tongue tie. BJA 2008:100;141‑2. 3. Potdar M, Patel RD, Dewoolkar LV. Molar intubation for Intra oral swellings: Our Experience. Indian J Anaesth. 2008;52:861. 4. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59:675-94. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.135094
Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014
A patient with acute abducens nerve palsy for lower segment caesarean section Sir, A full term 32‑year‑old parturient with Gradenigo’s syndrome was scheduled for a lower segment caesarean section (LSCS). She had isolated left abducens nerve (AN) palsy due to apical petrositis diagnosed on magnetic resonance imaging. She had complaints of severe headache on and off associated with vomiting for 7 days and diplopia involving left eye for 4 days. She was haemodynamically stable and pregnancy induced hypertension was ruled out. She was on systemic antibiotics and acetaminophen 650 mg 8th hourly and had received counselling about the disease. Elective LSCS was planned as it was precious pregnancy for the couple. On preanaesthesia check‑up, she was found to have no other systemic illness and no contraindication for regional anaesthesia. Her coagulation parameters were normal. Her routine investigations (complete blood picture, urea, creatinine, and serum electrolytes) were within the normal limits. Surgery was completed under general anaesthesia with Sellick’s manoeuvre, using thiopentone, succinylcholine, and oxygen, nitrous oxide, fentanyl, and vecuronium maintenance on controlled ventilation. She improved clinically after 5 weeks. Gradenigo’s syndrome comprises a triad of suppurative otitis media, pain along distribution of trigeminal nerve and AN palsy. The causes are apical petrosis due to suppurative otitis media and extradural inflammation at petrous apex involving trigeminal ganglion and AN. If untreated, it can lead to meningitis, intracranial abscess, prevertebral/parapharyngeal abscess, spread to sympathetic plexus and involve IX, X, XI cranial nerves (CNs) (Vernett’s syndrome).[1] All CNs, with the exception of I, IX, X can be affected following dural puncture. VI CN palsy is more common owing to its long intracranial course, which leads to traction and stretching of the nerve due to cerebrospinal fluid loss. Cain et al. conducted a systematic literature review of AN palsy due to dural puncture and found that there were 28 patients with temporary and permanent AN palsy (a total of 17 case reports and 5 case series).[2] The procedures, which 359
Copyright of Indian 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.
