The use of the laryngeal mask airway device (LMAD) for nasal and sinus surgery has been previously reported and accepted as an alternative to the endotracheal tube.1–5 The reinforced flexible LMAD is generally preferred because its flexible, longer, and thinner barrel offers better access to the surgical field. When placed properly, the mask of the LMAD covers the glottis and protects the glottis and subglottic area from blood that accumulates in the pharynx during surgery. However, the glottic seal formed by the mask is variable and dynamic, depending on the relative size of the mask, the adequacy of the placement, the mass of the soft tissue and the muscle tone in the pharyngeal area, the depth of anesthesia, and the stimulation of the surgery. Although the true incidence is unknown, leaking of blood into the glottic area and down the trachea has been reported in cases of LMAD use during nasal and sinus surgeries.1–4 To minimize the risk of aspiration of blood, throat gauze packs have been used to absorb blood and to help the seal of the mask around the glottis, similar to what has been used in conjunction with an endotracheal tube. However, the efficacy of the throat pack in blocking blood from entering the aerodigestive tract is questionable and may cause postoperative sore throat,6,7 particularly when bleeding is significant or the surgery is prolonged.
In this report, 2 suction catheters were embedded along the dorsal surface of a flexible LMAD that was used for a prolonged nasal surgery, during which significant amounts of blood were evacuated from the pharynx. The patient provided written permission for publication of the report.
A written consent for publication has been obtained from the patient.
The patient was a 24-year-old female with American Society of Anesthesiologists physical status II, a body height and weight of 168 cm and 65 kg, respectively (body mass index of 23 kg/m2), who presented for revision rhinoplasty, septoplasty, and chin implant. The total procedure was scheduled for 5 hours. After evaluation of the patient’s airway, a size 4 flexible LMA® mask (Teleflex Medical, Research Triangle Park, NC) was chosen, and 2 12F Tri-Flo suction catheters (CareFusion, Yorba Linda, CA) were embedded in the grooves on the back of the mask (Figure) using Steri-Strips (3M Health Care, St. Paul, MN) to securely attach the catheters to the distal end of the flexible tube.
After applying standard monitors, anesthesia was induced with midazolam 2 mg and fentanyl 25 μg, followed by propofol 150 mg (2.3 mg/kg). Alfentanil 500 μg was administered to further blunt the airway reflex. The modified LMAD was inserted in standard fashion after confirmation of adequate jaw opening, with care taken not to bend the tips of the suction catheters. The efficacy of the LMAD was confirmed by assessing lung compliance during manual ventilation, leak pressure, and the capnography waveform. After the patient’s head was positioned to meet surgical need, the LMAD was reassessed for proper function.
Anesthesia was maintained with 50% N2O in oxygen, 0.5% to 0.8% of end-tidal sevoflurane, and propofol infusion at 60 μg·kg−1.minute−1. Pressure-controlled ventilation was used. On return of spontaneous respiration toward the end of surgery, pressure-support ventilation was initiated, and respiratory rate was controlled with incremental bolus doses of 12.5 µg fentanyl.
At the start of the surgery, topical anesthesia with 4% cocaine-soaked pledgets was applied to both nostrils and was further supplemented by an injection of local anesthetic submucoperichondrially and in the marginal area, using 0.25% bupivacaine with 1:200,000 epinephrine. Additional amounts of local anesthetic were injected during the procedure, particularly before performing osteotomy.
Before surgical draping, the 2 embedded suction catheters were tested by applying vacuum to remove the spilled local anesthetics and minor bleeding. After completion of the chin implant and during the rhinoplasty and septoplasty, blood in the pharyngeal area was intermittently evacuated by applying brief suction that lasted a few seconds at a time, alternating between the 2 catheters during periods of active bleeding. The frequency of suction varied, depending on the amount of bleeding, with the goal of preventing blood accumulation in the pharynx while also avoiding potential injury to the mucosa. At the end of surgery, the volume of blood, surgical debris, and secretions removed from the pharyngeal area was measured with a syringe and recorded.
At the conclusion of surgery, all anesthetics were titrated off to allow time for nose packing and splint cast. The operating table was then placed in a back-up position with the patient’s head raised slightly to facilitate drainage of postnasal blood and to better support spontaneous respiration. Suctioning was frequently applied to the catheters to remove blood from the pharyngeal area during the emergence. Five minutes after the surgery was complete, when the patient was able to open her mouth on command, the LMAD was removed without deflating the cuff and with continuous suction applied to one of the catheters. On inspection, the 2 catheters remained in place and had no clot, and the inner aspect of the mask had no blood soiling. After reassessment of the patient’s status, the patient was transferred to the recovery room, awake and in stable condition. She reported no nausea, vomiting, sore throat, or hoarseness.
The LMAD has been recognized as an alternative method of ventilation and airway management for nasal and sinus surgeries for more than 2 decades.8–10 The avoidance of endotracheal intubation, smooth emergence from anesthesia with lower risk of surgical bleeding and fewer respiratory complications, and reduced patient discomfort make the use of the LMAD attractive to anesthesiologists, surgeons, and patients. However, despite these advantages, endotracheal intubation remains the preferred method for most anesthesiologists not specialized in ear, nose, and throat surgery. The potential risk of aspiration of blood and surgical debris and limited airway access during surgery are likely the main concerns and sources of reluctance.
While the mask of the LMAD may cover the glottis and act as a shield to prevent blood from entering the glottis and trachea during nasal and sinus or other upper airway surgeries, this assumption of protection is dependent on the soft end-to-end seal between the mask and the glottis. Currently, the seal may only be assessed indirectly based on parameters such as air leak, airway pressure, and tidal volume, but none of these surrogates can guarantee a perfect seal. In addition, changes in head and/or neck position as well as in airway muscle tone during the surgery can affect the efficacy of the seal. While effective ventilation does not necessarily require a perfect seal of the glottis by the LMAD, an optimal seal is needed to prevent blood that has accumulated in the pharynx from entering the glottis, or the blood must be removed promptly and efficiently before it accumulates. Although the incidence is reported to be lower with LMAD, complications such as airway blood contamination, coughing, laryngospasm, and oxygen desaturation during nasal surgery have been observed with endotracheal tubes and LMADs,1,2 probably due to blood accumulation in the pharynx or improper seal. Additionally, Kaplan et al3 have also demonstrated with bronchoscopy that blood can enter the glottic area when the LMAD is used for nasal and sinus surgery, and once in the glottic area, it is more likely to descend into the distal trachea. Specifically, blood was seen in the glottic area in 19.5% of the patients receiving LMAD, and in 75% of those cases, blood also entered the distal trachea. These incidences underscore the importance of a proper seal of the LMAD as well as the prevention of blood pooling above the LMAD. Moreover, anecdotal incidents of intraoperative blood aspiration during upper airway surgery with LMAD have been reported at times, and may have contributed to the slow acceptance of use of the flexible LMAD for nasal and other upper airway surgeries in many hospitals.
Large amounts of blood leaking into the glottic area likely pose a higher risk of respiratory complications. This is of special concern if the operation is prolonged as in our case. Bleeding during nasal and sinus surgery varies among patients and surgeons and is difficult to predict, despite the use of vasoconstrictive agents (cocaine, oxymetazoline, and epinephrine) or controlled hypotension.5 For example, while most nasal surgeries such as septoplasty and rhinoplasty cause only minimal bleeding, excessive bleeding during functional endoscopic sinus surgery is not uncommon and has been reported to be as much as over 200 mL.5 Therefore, it is important that blood from the pharyngeal area can be promptly and effectively evacuated in order to minimize the risk of aspiration when using LMAD for nasal and sinus surgery.
In this case, blood soiling inside the mask did not occur even though >70 mL of blood was evacuated from the pharynx. Although bronchoscopic evidence was not obtained (as bronchoscopy is not part of routine practice), the uneventful intraoperative course as well as the smooth emergence supports the visual inspection finding that no blood entered the bowl of the LMAD or the glottis and lower airway during the prolonged operation. This result is at least partly attributed to the avoidance of blood pooling above the LMAD, and is consistent with the author’s past 13 years experience of using this method for nasal and sinus surgeries, which normally last an hour or less. In addition, the pharyngeal suction catheters may facilitate clearing residual postnasal blood and oral secretions immediately before or during the removal of the LMAD, thereby reducing the potential risk of laryngospasm, as well as coughing and straining, which are particularly harmful in facial plastic and inner ear surgery. This is especially valuable when direct oral suctioning is ineffective or impossible, such as when mouth opening is limited (as in facelift) or when the patient is uncooperative.
In conclusion, adding pharyngeal suction capability to the LMAD can potentially minimize the risk of blood soiling of the aerodigestive tract during nasal and sinus surgery, and may reduce the risk of coughing and laryngospasm during emergence from anesthesia and removal of the LMAD. A formal study is needed to evaluate its efficacy and safety.
Name: Gary X. Zhou, MD.
Contribution: This author created the method, provided patient care, and wrote the manuscript.
This manuscriptwas handled by: Hans-Joachim Priebe, MD, FRCA, FCAI.
The author wishes to thank Dr Kirk Shelley and Dr William Rosenblatt for reviewing the manuscript.
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