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LETTER TO THE EDITOR

Difficult Intubation in a Patient Without a Mandibular Body

Department of Dental Anesthesiology; Kagoshima University Graduate School of Medical and Dental Sciences; Sakuragaoka, Kagoshima; Japan; sugi{at}dentc.hal.kagoshima-u.ac.jp

To the Editor:

For patients with an anticipated difficult intubation due to the oral and maxillofacial deformity, awake fiberoptic tracheal intubation is usually selected. However, fiberoptic intubation is not always successful.1

A 64-yr-old man was scheduled for oral surgery under general anesthesia. His mandibular body had previously been completely resected due to a prior surgical procedure, and the lower half of his face was markedly retracted (Fig. 1). The tip of his tongue was barely visible behind the pectoralis major myocutaneous (PMMC) flap when he opened his mouth (Fig. 2). These findings indicated that a difficult intubation was anticipated.

View larger version (53K): [in this window] [in a new window]   Figure 1. Patient's features. The lower half of his face was markedly retracted.

View larger version (59K): [in this window] [in a new window]   Figure 2. Intraoral findings with the mouth open. The tip of his tongue was barely visible behind the PMMC flap.

After IV administration of 50 µg fentanyl with subsequent infusion of propofol at a rate of 2 mg · kg^–1 · h^–1, adequate topical anesthesia of the larynx was achieved using 4% lidocaine. Awake nasotracheal intubation was attempted using a fiberoptic bronchoscope (FOB) (outside diameter 4.1 mm) and the endotracheal tube (ETT) (inner diameter 8.0 mm). Although anterior flexion of the tip of the FOB enabled visualization of the glottic opening, it was difficult to insert the ETT into the trachea because the tip of the ETT, as well as the FOB, headed posteriorly. The body of the mandible, the base of the tongue, and the muscles of the oral floor had been replaced by the scar tissue causing cicatrical contracture with consequent stiffness of the anatomical structures and anterior displacement of the glottis. After the ETT was withdrawn slightly, it was rotated counterclockwise, and again advanced several times but tracheal intubation was ultimately impossible.

The FOB was removed from the ETT and the Styletscope was inserted into the ETT.2 The Styletscope consists of a fiber-stylet component and a scope-body component with a built-in battery (Fig. 3A). By depressing the lever attached to the body, the distal tip of the stylet part can be flexed anteriorly (Fig. 3B). The prominent feature is that the Styletscope inserted into the ETT allows manual control of the flexion of the ETT with little force. The anterior flexion of the ETT tip over the Styletscope enabled us to advance the ETT toward the glottis. The reason for failed fiberoptic intubation in our patient was probably due to the fact that the FOB could not bend the ETT tip anteriorly. Our experience suggests that the anterior flexion of the ETT tip may be required in patients without the mandibular body.

View larger version (54K): [in this window] [in a new window]   Figure 3. Styletscope. (A) The Styletscope consists of a fiber-stylet and a scope-body. (B) By depressing the lever attached to the body, the distal tip of the style can be flexed anteriorly.

Recently, the EndoFlex^TM tube (Merlyn Medical, Tustin) has been clinically available. The tip of the EndoFlex^TM tube can be flexed by the friction lock. We believe that the use of the EndoFlex^TM tube combined with the FOB can facilitate the glottic visualization and tracheal intubation in patients with a difficult fiberoptic intubation.

REFERENCES

1. Johnson DM, From AM, Smith RB, From RP, Maktabi MA. Endoscopic study of mechanisms of failure of endotracheal tube advancement into the trachea during awake fiberoptic orotracheal intubation. Anesthesiology 2005;102:910–14[Web of Science][Medline]
2. Kihara S, Yaguchi Y, Taguchi N, Brimacombe JR, Watanabe S. The Styletscope is a better intubation tool than a conventional stylet during simulated cervical spine immobilization. Can J Anaesth 2005;52:105–10[Web of Science][Medline]

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