Airway Management During Second-Stage Tongue Flap Procedure

To the Editor:

In their Letter to the Editor regarding intubation for flap division in a second-stage, tongue-flap procedure, Eipe et al. (¹) suggested it is advisable to avoid nasal intubation after any palatoplasty, as even a carefully visualized nasotracheal intubation may damage or disrupt the recently reconstituted nasal layer. Fiberoptic intubation is definitely superior to direct laryngoscopy in securing the airway in patients with a tongue flap attached to the palate. However, we use a different technique that minimizes the risk of bleeding or trauma to the flap.

The tongue flap is divided under local anesthesia, without vasoconstrictors, before general anesthesia. Two silk threads are tied towards the tongue end of the flap, and the flap is divided between them. This technique prevents bleeding. If bleeding occurs, it is immediately cauterized with bipolar cautery. Once the flap is divided, the anesthesiologist induces general anesthesia and proceeds with conventional orotracheal intubation.

The only challenge is the patient’s compliance for dividing the flap under local anesthesia. Usually this division is not performed in children, as patient cooperation is essential. Our patients, mostly in their mid to late teens, cooperate well with the procedure. Bleeding has never been a problem. This division technique should also be useful in patients with an existing pharyngeal flap. Because the flap has been divided under local anesthesia, nasotracheal fiberoptic intubation need not be attempted, thus facilitating orotracheal intubation.

Sherry Peter, FDSRCS, FRCS

Pramod Subash, MDS, DNB, MOMS RCPS

Division of Cranio-Maxillofacial Surgery

Head and Neck Institute

Amrita Institute of Medical Sciences

Kochi, Kerala, India

[email protected]

Jerry Paul, MD

Department of Anaesthesiology

Amrita Institute of Medical Sciences

Kochi, Kerala, India