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LETTER TO THE EDITOR

Intubation Using an LMA and Gum Elastic Bougie

Department of Anesthesia, Massachusetts General Hospital, Boston, MA, jaydevsarma{at}hotmail.com

To the Editor:

A 56-year-old male patient presented with an enlarged thyroid gland for a subtotal thyroidectomy under general anesthesia. He was 72-in tall, weighed 210 pounds, and had a history of smoking 2 packs of cigarettes a day for over 25 years. He had never had surgery and was not on any medication. He did complain of hoarseness of the voice and some mild dyspnea on exertion. Routine airway examination was unremarkable. He was induced with 2 mg/kg of propofol and 150 µg of fentanyl and, after determining that mask ventilation was easy, he was given 12 mg of cisatracurium for muscle relaxation. Laryngoscopy was attempted with Macintosh size 3 and 4 blades without being able to visualize the larynx. A size 5 laryngeal mask airway (LMA) was passed and ventilation could be performed. A fiberoptic bronchoscope was then inserted through the LMA and the vocal cords appeared to be inflamed and edematous. Two attempts at passing an endotracheal tube through the LMA were unsuccessful. Under direct fiberoptic vision, a gum elastic bougie was passed through the vocal cords and the LMA and fiberoptic bronchoscope were removed and a 7-mm cuffed endotracheal tube was threaded over the gum elastic bougie and the airway was secured.

The trachea was ventilated via the LMA between attempts and the oxyhemoglobin saturation never diminished below 90% throughout the procedure. The case proceeded uneventfully thereafter. At the end of the case, the neuromuscular blockade was reversed and the endotracheal tube was removed after the patient was fully awake and was able to follow commands. An otolaryngologist was called in for consultation during the case and he diagnosed Reinke's edema of the vocal cords. These patients usually present with hoarseness of the voice and have a history of heavy smoking. They also have polypoid degeneration of the vocal cords and can pose difficulty with intubation and even positioning of the LMA-like devices (1).

Reference

1. d'Hulst, Butterworth J, Dale S, et al. Polypoid hyperplasia of the larynx misdiagnosed as a malpositioned laryngeal mask airway. Anesth Analg 2004;99:1570–2.[Abstract/Free Full Text]

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