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Anesthesiology:
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Laryngospasm‐The Best Treatment

Larson, Philip C. Jr. MD

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To the Editor:‐When considering the treatment of laryngospasm, standard textbooks of anesthesiology suggest virtually the same sequence: namely jaw thrust at the angle of the mandible while applying positive‐pressure ventillation with oxygen, 100%, by bag and mask and, if that fails, administering succinylcholine, the recommended dose varying from 0.25 to 1 mg/kg intravenously or 4 mg/kg intramuscularly. [1‐8] In addition, some texts recommend suctioning foreign material from the oropharynx, administering lidocaine, 1 to 1.5 mg/kg, and removing or avoiding any painful stimulus. One author recommended digital elevation of the tongue by inserting an index finger deep into the pharynx, a treatment of substantial risk to the therapist. [9]
Figure 1
Figure 1
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Almost 40 years ago, Dr. N. P. Guadagni showed me a technique for prompt termination of laryngospasm, which I have used countless times with complete success. Because I have used the techniques so often myself and have taught it to hundreds of residents and nurses, I presumed that it was common knowledge and well documented in the literature. However, a thorough literature search has not revealed any mention of it. The technique involves placing the middle finger of each hand in what I term the laryngospasm notch. This notch is behind the lobule of the pinna of each ear. It is bounded anteriorly by the ascending ramus of the mandible adjacent to the condyle, posteriorly by the mastoid process of the temporal bone, and cephalad by the base of the skull (Figure 1). The therapist presses very firmly inward toward the base of the skull with both fingers, while at the same time lifting the mandible at a right angle to the plane of the body (i.e., forward displacement of the mandible or “jaw thrust”). Properly performed, it will convert laryngospasm within one or two breaths to laryngeal stridor and in another few breaths to unobstructed respirations.
The most common mistake made by those learning the technique is to place the fingers lower on the ramus of the mandible or at the angle of the jaw. Pressure and forward displacement of the mandible at these locations will elevate the tongue from the posterior pharyngeal wall but will not correct laryngospasm. To be effective for laryngospasm, the pressure must be firm and must be applied at the most cephalad portion of the laryngospasm notch. It is desirable to administer oxygen while performing the technique. This is easily performed by holding a mask over the patient's face with the thumb and index fingers of each hand while using the middle fingers for applying pressure and forward displacement. The technique is effective in infants, children, and adults. Because the patient is making respiratory efforts at the time of treatment, there is no need to apply positive pressure on the reservoir bag of the anesthetic machine, although an assistant can do so if the anesthesiologist wishes. I believe this technique for treatment of laryngospasm is far superior to those recommended herein because it is absolutely reliable, it resolves the spasm more rapidly than positive pressure ventilation, and it is much quicker and safer than administering succinylcholine or lidocaine. The technique also may be used to maintain a patent airway during mask anesthesia.
The obvious question is, Why does it work? Unfortunately, a sound, scientific answer cannot be provided. It works in part because forward displacement of the mandible corrects airway obstruction caused by the tongue falling back against the posterior pharyngeal wall. However, contrary to the recommendation that painful stimulation be avoided, an essential component of the treatment is the severe pain that the patient experiences because of the firm pressure that is applied to the ramus of the mandible, the facial nerve, and perhaps the deep lobe of the parotid gland. The parotid gland is innervated in part by the glossopharyngeal nerve, which in turn has connections with the vagus nerve and the superior cervical sympathetic ganglion by way of the petrosal ganglion. [10] The interconnections of the nerves at this location are complex and specific functions are not completely understood. It is likely that the painful stimulus relaxes the vocal folds and vocal cords by way of either the parasympathetic or sympathetic nervous systems.
The thanks Helen Cambron, R.N., for the illustration.
C. Philip Larson, Jr., M.D.
Professor Emritus; Anesthesia and Neurosurgery; Stanford University; Professor of Clinical Anesthesiology; UCLA School of Medicine; plarson@ucla.edu
(Accepted for publication June 11, 1998.)
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REFERENCES

1. Fink BR: The etiology and treatment of laryngeal spasm. Anesthesiology 1956; 17:569-77

2. McGoldrick KE: Otorhinolaryngologic surgery, Ambulatory Anesthesiology, A Problem-Oriented Approach. Edited by McGoldrick KE. Baltimore, Williams & Wilkins, 1995, pp 459-506

3. McGee JP, Vender JS: Nonintubation management of the airway, Clinical Procedures in Anesthesia and Intensive Care. Edited by Benumof JL. Philadelphia, JB Lippincott, 1992, pp 89-114

4. Morgan GE, Mikhail MS: Clinical Anesthesiology. 2nd edition. Stanford, Appleton & Lange, 1996, p 68

5. Stehling LC: Management of the airway, Clinical Anesthesia. 2nd edition. Edited by Barash PG, Cullen BF, Stoelting RK. Philadelphia, Lippincott-Raven, 1992, pp 693-4

6. Brett CM, Zwass MS, France NK: Eyes, ears, nose, throat and dental surgery, Pediatric Anesthesia. 3rd edition. Edited by Gregory GA. New York, Churchill Livingstone, 1994, pp 657-97

7. Finucane BT, Santora AH: Complications of endotracheal intubation, Principles of Airway Management. 2nd edition. St Louis, Mosby, 1996, pp 227-50

8. Gwirtz KH: Management of recovery room complications, Anesthesiology Clinics of North America. Edited by Dierdorf SF. Philadelphia, WB Saunders Company, 1996, pp 307-39

9. Mark LC: Treatment of laryngospasm by digital elevation of tongue. Anesthesiology 1963; 24:585

10. Larsell O: The nervous system, Morris' Human Anatomy. 11th edition. Edited by Schaeffer JP. New York, The Blakiston Company, 1953, pp 1007-10

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