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Difficult Airway Management Following Supratentorial Craniotomy: A Useful Maneuver with a New Device

Osborn, Irene P. MD; Behringer, Elizabeth Cordes MD; Kramer, David C. MD

Section Editor(s): Saidman, Lawrence

doi: 10.1213/01.ane.0000268139.62137.f6
Letters to the Editor: Letters & Announcements

Division of Neuroanesthesia; Mount Sinai School of Medicine; New York, NY; (Osborn)

Department of Anesthesiology; University of California, Irvine; Orange, CA (Behringer)

Division of Neuroanesthesia; Mount Sinai School of Medicine; New York, NY (Kramer)

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To the Editor:

The McGrath® Video Laryngoscope (Aircraft Medical, Edinburgh, Scotland) is a video-based system for tracheal intubation that utilizes a video camera embedded into a “camera stick” (Fig. 1). The device can be disarticulated, which was critical in the urgent airway management of the following case:

A 31-year-old 62 kg ASA PS 2E female patient presented for urgent ventriculoperitoneal shunt because of hydroceplalus. She had undergone a left temporoparietal craniotomy 4 days prior for removal of an encephalocele. On examination, the patient was noted to have new limitation of her mouth opening (2.5 cm) because of incisional pain in the left temporal region. Review of the previous anesthetic record revealed no difficulty with intubation using the GlideScope® Model GVL 115 (Verathon Medical, Bothell, WA) electively for teaching purposes in this patient with a previously unremarkable airway examination. After induction and easy ventilation via a mask, succinylcholine 120 mg was administered IV. However, her mouth opening did not improve and one attempt at direct laryngoscopy with a MacIntosh 3 blade and one additional attempt using the GlideScope® were made. Neither device could be introduced into the mouth using standard technique with the patient’s head in “sniffing position.” Mask ventilation was easily maintained between attempts at laryngoscopy. The McGrath® laryngoscope blade and camera stick were disarticulated from its handle and easily inserted midline; similar to the insertion of a tongue depressor. The handle was re-attached revealing a Cormack/Lehane Grade 1 view of the glottis. The trachea was intubated without difficulty on the first attempt.

Kawaguchi et al. described the phenomenon of pseudoankylosis of the mandible after supratentorial craniotomy as “persistent limitation of mouth opening due to extra-articular pathology including infection, irradiation, burns, or surgical incision of the masticatory muscles” (1). He noted a significantly decreased maximum mouth opening in adult patients after frontotemporal craniotomy compared with those after occipital or limited frontal craniotomy occurring in as little as 3 days after surgery. Our patient had undergone left temporal craniotomy 4 days before reoperation.

The technique of disarticulating a standard laryngoscope is rarely practiced but is reportedly effective when large breasts impede conventional placement of the blade (2).

The ease of reattachment of the McGrath® Video Laryngoscope handle is due to unique end to side connection. The side of the handle connects to the end of the McGrath® blade. This feature allows the laryngoscopist to reconnect the handle and blade and so eliminating the obstacle posed by the patient’s chest, large breasts, or limited mouth opening. The inability to use the GlideScope® for this patient’s reoperation was because of its design. The GlideScope® is designed as a rigid, fused unit of medical grade plastic (3). The Glidescope® blade has a pronounced 60° angulation, a maximum width of 26 mm and a maximum thickness of 14.5 mm. The fused design of the Glidescope® did not allow the tip of the blade to pivot into the hypopharynx in this patient with limited mouth opening.

An additional virtue of video-laryngoscopy is that the position of the camera extends the laryngoscopist’s field of view from 10° with conventional laryngoscopy using line of sight to 60° utilizing video technology (4). The disarticulating design of the McGrath® Video laryngoscope allowed the trachea of a patient with limited mouth opening to be intubated easily.

Irene P. Osborn, MD

Division of Neuroanesthesia

Mount Sinai School of Medicine

New York, NY

Elizabeth Cordes Behringer, MD

Department of Anesthesiology

University of California, Irvine

Orange, CA

David C. Kramer, MD

Division of Neuroanesthesia

Mount Sinai School of Medicine

New York, NY

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1. Kawaguchi M, Sakamoto T, Furuya H, Ohnishi H, Karasawa J. Pseudoankylosis of the mandible after supratentorial craniotomy. Anesth Analg 1996;83:731–4
2. Hagberg CA. Special devices and techniques. Anesthesiol Clin North America 2002;20:907–32
3. Cooper RM, Pacey JA, Bishop MJ, McClusky SA. Early clinical experience with a new Videolaryngoscope (GlideScope®) in 728 patients. Can J Anaesth 2005;52:191–8
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© 2007 International Anesthesia Research Society