a case of a difficult airway due to large sublingual dermoid in a rural medical college

Access this article online Quick response code Website: www.ijaweb.org DOI: 10.4103/0019-5049.115585 A case of a difficult airway due to large sublingual dermoid in a rural medical c

Letters to Editor

313 Indian Journal of Anaesthesia | Vol 57| Issue 3 | May-Jun 2013

Address for correspondence:

Dr Rajender Kumar, A‑22, Sai Apartment, Plot No 47, Sector‑13, Rohini,

New Delhi ‑ 110 085, India

E‑mail: drrbarua@rediffmail.com

REfEREnCES

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RJ, Harp S The slipping rib syndrome in children Paediatr

Anaesth 2001;11:740‑3.

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referred pain of visceral diseases and a consideration of

these from the point of view of cause and effect Practitioner

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3 Davies‑Colley R Slipping rib Br Med J 1922;1:432.

4 Holmes JF Slipping rib cartilage with report cases Am J Surg

1941;54:326‑38.

5 Holmes JF A study of the slipping rib‑cartilage syndrome N

Engl J Med 1941;224:928‑32.

6 Udermann BE, Cavanaugh DG, Gibson MH, Doberstein

ST, Mayer JM, Murray SR Slipping Rib Syndrome in a

Collegiate Swimmer: A Case Report J Athl Train 2005;

40:120‑2.

7 Keoghane SR, Douglas J, Pounder D Twelfth rib

syndrome: a forgotten cause of flank pain BJU Int 2009;

103:569‑70.

8 Machin DG, Shennan JM Twelfth rib syndrome: a

differential diagnosis of loin pain BMJ (Clin Res Ed) 1983;

287:586.

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10.4103/0019-5049.115585

A case of a difficult airway due

to large sublingual dermoid in a

rural medical college

Sir,

Giant size sublingual dermoid cysts are extremely

rare and pose considerable technical challenges to

the anesthesiologists We report a case posted for

marsupialization of cyst with a tentative diagnosis of

congenital ranula and ectopic thyroid as differential

diagnosis

A 29‑year‑old patient complained of a slow growing

swelling inside the mouth, first noticed in childhood

The patient complained of pain in the swelling,

dysarthria, dysphagia, and mild respiratory distress

on lying supine after needle aspiration biopsy Airway

examination revealed a smooth tender immovable mass 3 × 4 cm on the floor of the mouth occupying the entire oral cavity and displacing the tongue against the hard palate making visualization of the tongue difficult There was limited temporomandibular joint movement and normal thyromental distance Lateral X‑ray of neck in the standing position revealed narrowing of the oropharynx [Figure 1] Preoperative indirect laryngoscopy was attempted by the otolaryngologist; however, glottic structures were not visualized

Consent for fiberoptic nasal intubation under general anesthesia was obtained and the patient was premedicated with injection Glycopyrolate 0.2 mg i.v and injection Metoclopramide 10 mg i.v 30 min before procedure Emergency invasive airway access was kept ready in the case of failed intubation Pulse oximeter, electrocardiogram, and end tidal carbon dioxide monitors were connected and baseline parameters recorded Injection Fentanyl 100 μgm i.v was given and nasal mucosa anaesthetized with cotton pledgets soaked in 3 ml 4% lignocaine and 0.5 ml xylometazoline

After preoxygenation with 100% oxygen for 3 min, anesthesia was induced with halothane in oxygen and nitrous oxide (33:67%) Mask‑assisted ventilation was possible during spontaneous breathing Fiberoptic bronchoscopy through the nasal cavity was performed under spontaneous breathing The fiberoptic view was poor, epiglottis was not visible, hence jaw thrust was provided and vocal cords were visualized Lignocaine 4% was sprayed onto vocal cords Adequacy of inhalational and local anesthesia was verified, scope was advanced under the epiglottis through the vocal

Figure 1: Lateral X‑ray of neck in standing position

Letters to Editor

Indian Journal of Anaesthesia | Vol 57| Issue 3 | May-Jun 2013 314

diagnosis have the potential for converting an anticipated difficult airway into a dangerously difficult airway.[3‑5]

Nasal fiberoptic intubation was chosen as it was not possible to pass both scope and tube in the highly limited oral cavity As the patient refused bronchoscope placement while awake, general anesthesia using volatile anesthetic agents was chosen When spontaneous ventilation is maintained, the changes in depth of anesthesia and associated respiratory and cardiovascular effects occur gradually and can be easily reversed with the use of volatile anesthetic agents.[6]

Fiberoptic nasotracheal intubation while maintaining spontaneous breathing under inhaled anesthesia is one of the recommended methods of securing the airway in uncooperative patients with large sublingual dermoid

Lavanya Kaparti, T Mahesh

Department of Anaesthesiology, PESIMSR, Kuppam,

Andhra Pradesh, India

Address for correspondence:

Dr Lavanya Kaparti,

C 57, Officers Quarters BEML Nagar, Kolar Gold Fields,

Kolar ‑ 563 115, Karnataka, India E‑mail: drlavanyakaparti@yahoo.com

REfEREnCES

1 King RC, Smith BR, Burk JL Dermoid Cyst in the Floor of the Mouth Review of the Literature and Case Reports Oral Surg Oral Med Oral Pathol 1994;78:567‑76.

2 Raveenthiran V, Sam CJ, Srinivasan SK A simple approach to airway management for a giant sublingual dermoid cyst Can J Anesth 2006;53:1265‑6.

3 Naveen E, Doreen Y Airway management for intra‑oral surgery – airway first Can J Anesth 2007;54:488‑89.

4 Eipe N, Pillai AD, Choudhrie A, Choudhrie R The tongue flap: An iatrogenic difficult airway? Anesth Analg 2006;102:971‑3.

5 Kummer C, Netto FS, Rizoli S, Yee D A review of traumatic airway injuries: Potential implications for airway assessment and management Injury 2007;38:27‑33.

6 Brooks P, Ree R, Rosen D, Ansermino M Canadian pediatric anesthesiologists prefer inhalational anesthesia to manage difficult airways Can J Anesth 2005;52:285‑90.

cords till the carina was visualized A 6.0 mm cuffed

endotracheal tube was advanced into the trachea over

the scope Oxygenation was adequate throughout

intubation Anesthesia was maintained with

halothane, oxygen, nitrous oxide, and vecuronium

bromide as necessary

An intraoperative diagnosis of dermoid was made

[Figure 2] At the completion of surgery, direct

laryngoscopy showed laryngeal grade 2 view (Cormack

and Lehane classification) As supraglottic edema

was not anticipated, patient was extubated when

fully awake Postextubation vital parameters were

within normal range and patient maintained oxygen

saturation (SpO2) of 97‑98% in room air

Sublingual dermoid cysts account for less than 1%

of cystic intraoral lesions and fewer than 225 cases

have been reported in the literature.[1] Various

airway management strategies have been suggested

such as blind nasotracheal intubation, fiberoptic

endoscope‑guided intubation and preliminary

tracheostomy Blind nasotracheal intubation requires

extensive practice prior to use and carries the risk

of bleeding and trauma Preliminary tracheostomy

significantly increases morbidity

Excision under local anesthesia with monitored

anesthesia care carries significant risk of intra

operative pulmonary aspiration Decompression

of dermoid cyst by aspirating its contents prior

to intubation to facilitate intubation has been

reported.[2] This was not attempted in our case as a

preoperative diagnosis was not made and surgical

procedures in the airway preceding a definitive

Figure 2: Maximum mouth opening achieved under general

anaesthesia with muscle relaxation

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DOI:

10.4103/0019-5049.115588

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