Anesth Analg 2006;102:971-973
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000190880.93675.1D
LETTER TO THE EDITOR
The Tongue Flap: An Iatrogenic Difficult Airway?
Naveen Eipe, MD,
A. Dildeep Pillai, MS,
Ashish Choudhrie, MS, and
Rajiv Choudhrie, MCh
Department of Anesthesia, neipe{at}yahoo.com(Eipe)
Department of Surgery(Pillai, Choudhrie)
Department of Plastic Surgery, Padhar Hospital, Padhar, Madhya Pradesh, India(Choudhrie)
To the Editor:
Tongue flap surgery for cleft palate repair involves two separate operations. In the first operation, a tongue flap is created to close the palatal defect (1). In the second operation, the flap is divided, freeing the tongue from the palate. Airway management for the second operation is complicated by the flap between the tongue and the palate. We describe the airway management in two patients who had undergone tongue flap surgery in this hospital and were scheduled for division of the flap.
Nasotracheal intubation was performed in the first patient (age 15 yr, weight 39 kg) to secure the airway during initial closure of the palatal fistula with a tongue flap. For the flap division procedure, we planned to divide the flap using IV sedation and local anesthesia, followed by induction of anesthesia and orotracheal intubation after the flap was divided. The patient was sedated with IV ketamine 50 mg. Glycopyrrolate 0.2 mg was administered to control secretions. The surgeons inserted a mouth gag and proceeded to divide the flap with the patient breathing spontaneously. After successful flap division, the patient was anesthetized, paralyzed, and orotracheal intubation was performed under laryngoscopic visualization without incident.
In the second patient (age 14 yr, weight 44 kg) nasotracheal intubation was also performed to secure the airway during initial closure of the palatal fistula (Fig. 1). As expected, when the patient subsequently presented for flap division, the tongue flap compromised direct laryngoscopy (Fig. 2). We planned to secure the airway before the division of the flap to preclude the possibility of bleeding into an unsecured airway. Anesthesia was induced with IV ketamine 75 mg followed by ventilation with oxygen and nitrous oxide 50:50 and 1% halothane. Preliminary laryngoscopy was performed with the head turned to the right and the laryngoscope blade carefully inserted to the left of the flap (retromolar approach). The view was Grade 3 (2). Succinylcholine IV 50 mg was administered, and, using direct laryngoscopy, an orotracheal tube was passed to the left of the flap (Fig. 3).
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Figure 1. Intraoperative photograph showing the palatal defect and nasal intubation (tongue flap construction surgery).
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Figure 3. Intraoperative photograph showing the orotracheal intubation lateral to the flap (tongue flap division surgery).
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The tongue flap technique is based on the use of a flap constructed from the dorsum of the tongue to close a defect in the palate (1). These airways are readily managed for the initial flap construction surgery using nasal intubation (3). Securing the airway for the tongue flap division surgery is more challenging (4). After any palatoplasty it is advisable to avoid nasal intubation, as this may damage or disrupt the recently constructed flap (5). We have described two different approaches, securing the airway either after (patient 1) or before (patient 2) division of the flap. Securing the airway after the flap has been separated, as in the first case, may be difficult if there is excessive bleeding from the edges of the divided flap. This is why we chose tracheal intubation under direct laryngoscopy for the second patient. However, this approach poses a risk of trauma to the flap. In our view neither of the approaches described are ideal. We intend to secure the airway for future cases using fiberoptic oral intubation.
References
- Guzel MZ, Altintas F. Repair of large, anterior palatal fistulas using thin tongue flaps: long-term follow-up of 10 patients. Ann Plast Surg 2000;45:109–17.[Medline]
- Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984;39:1105–11.[ISI][Medline]
- Naik L, Jagtap S, Sawant P. Anesthesia for tongue flaps in infants. Plast Reconstr Surg 1993;92:172.
- Hochberg J, Naidu R, Saunders DE. Anesthesia technique for serving the pedicle of a tongue flap in the presence of a pharyngeal flap. Plast Reconstr Surg 1978;62:905–6.[Medline]
- Solan KJ. Nasal intubation and previous cleft palate repair. Anaesthesia 2004;59:923–4.[Medline]
