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LETTER TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 95-96
 

Paraglossal approach of laryngoscopy with miller blade in adult with large tonsillar mass


Department of Anaesthesiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Date of Web Publication15-Nov-2018

Correspondence Address:
Dr. Rajnish Kumar
Q. No D2/5, IGIMS Campus, Sheikhpura, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_16_18

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How to cite this article:
Arun N, Kumar R, Kumar A. Paraglossal approach of laryngoscopy with miller blade in adult with large tonsillar mass. Indian Anaesth Forum 2018;19:95-6

How to cite this URL:
Arun N, Kumar R, Kumar A. Paraglossal approach of laryngoscopy with miller blade in adult with large tonsillar mass. Indian Anaesth Forum [serial online] 2018 [cited 2019 Oct 22];19:95-6. Available from: http://www.theiaforum.org/text.asp?2018/19/2/95/245535




Sir,

We are sharing our experience of successful airway management in a patient with huge, fragile and vascular tonsillar mass, nearly obstructing the oropharynx. A 55-year-old male weighing 80 kg, American Society of Anaesthesiologists physical status-1 was admitted with a complaint of mass in oral cavity for the last 3 months. It was a tonsillar mass, arising from the right side and completely obstructing the airway, was painless, rapidly progressing and sometime bled on coughing and there was change in voice to nasal tone [Figure 1]. Airway examination revealed it to be Mallampati Grade 4, mouth opening was adequate with normal range of neck movement and mass moved with respiration. There was no history of obstructive sleep apnea. Computed tomography of the neck revealed isolated soft-tissue mass seen in the right tonsillar fossa projecting in the oropharynx occluding the lumen, adjacent vessels were normal. For airway management, flexible fiberoptic devices are of great help but due to their unavailability, we had planned to assess the airway through fiber optic flexible nasopharyngoscopy (6 mm karl storz) in the ENT department. Nasopharyngoscope was introduced from the left side of mouth showed normal vocal cord movement, epiglottis was large, hanging, and deviated to the left because of pressure effect of tonsillar mass. Nasopharyngoscopy was not possible through nose because mass was obstructing the nasopharyngeal passage. Informed written consent was obtained and preparations were made for emergency tracheostomy, if required. He was fasted for 6 h before surgery.
Figure 1: Enlarged tonsillar mass

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In the operation room after securing intravenous line and applying a monitor, baseline vital parameters were recorded. Oropharynx was anesthetized by 5 puffs of 10% lignocaine spray. He was preoxygenated for 5 min. Followed by administration of midazolam 1.5 mg, Fentanyl 2 μgm/kg intravenously. Inhalational induction was done with incremental increase in concentration of sevoflurane in 50% NO2 and 50% O2. We were able to ventilate the patient which was confirmed by visible chest rise and capnography. Succinylcholine 75 mg intravenously was injected for ease in the negotiation of the laryngoscope blade. The modified paraglossal technique was used for tracheal intubation with straight Miller laryngoscope blade from the left side. This facilitated us to negotiate narrow and straight laryngoscope blade in minimal available oropharyngeal space gently, shifting the pedunculated right tonsillar mass to the right, giving us just enough space to reach posterior to the epiglottis. Then, blade was lifted, Cormack Lehane Grade was 2b. Trachea was intubated with assistance of gum elastic bougie with internal diameter 7 mm of endotracheal tube and bilateral equal air entry was confirmed. Anesthesia was maintained with oxygen, nitrous oxide, sevoflurane, and vecuronium. Vital parameters were stable during intraoperative period. Trachea was extubated after reversal of neuromuscular blockade. His subsequent hospital stay was uneventful.

Large tonsillar mass in an adult is very rare. We had anticipated difficulty in mask ventilation after induction, difficult laryngoscopy from the right side with curved blade and chances of bleeding. That is why, we had introduced Miller blade from the left side. We had planned for inhalational induction keeping in mind obstructive symptoms of the patient, as fast intravenous induction might have caused airway obstruction due to loss of oropharyngeal tone. In the basic paraglossal technique of intubation, the straight blade is inserted in the extreme right corner of the mouth opening and advanced undervision paraglossal along the groove between the tongue and the tonsil until the epiglottis is visualized. Thereafter, the blade is passed posterior to epiglottis and lifted anteriorly, elevating the epiglottis to expose the glottis, and tracheal intubation is performed.[1] The improved visualization is due to soft-tissue compression, due to narrowness of Miller blade and straight line of sight provided by straight blade ensures a continuous view of the larynx. The effectiveness of paraglossal technique over conventional approach in better glottic visualization and ease of intubation has a been reported by Jindal et al. and Anderson et al.[2],[3] Similar case of airway management in patient with tonsillar growth was reported by Agrawal et al. where authors have documented that paraglossal technique led to successful intubation in cases where Macintosh blade fails.[4] To conclude that we must be well versed with different laryngoscope blade and techniques as selection of the right blade and the right technique can make difficult things easier.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Henderson JJ. The use of paraglossal straight blade laryngoscopy in difficult tracheal intubation. Anaesthesia 1997;52:552-60.  Back to cited text no. 1
    
2.
Jindal P, Khurana G, Gupta D, Chander U. Can paraglossal approach be an effective alternative to the conventional laryngoscopy in routine anaesthesia practice – A comparative study. J Anesth Clin Res 2014;5:406.  Back to cited text no. 2
    
3.
Anderson P, Espinaco J, Vorster JG. Successful difficult airway intubation using the Miller laryngoscope blade and paraglossal technique. South Afr J Anaesth Analg 2015;21:2, 46-8.  Back to cited text no. 3
    
4.
Agrawal S, Asthana V, Meher R, Singh DK. Use of paraglossal straight blade intubation technique in difficult intubation. Indian J Anaesth 2008;52:317-20.  Back to cited text no. 4
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