To the Editor
Flexible fiberoptic intubation (FOI) is often chosen during airway management in pediatric patients recovering from facial burns and now returning for plastic reconstructive surgery.
Under general anesthesia the loss of muscle tone in the pharyngeal and laryngeal structures, and apposition of the tongue base to the posterior pharyngeal wall1 may obscure the operator's view of the laryngeal aperture during FOI. Although anterior tongue traction alone or supplemented with jaw thrust,2 grasping forceps, malleable tongue retractor, hand grasping with gauze, and zero silk sutures have been used to pull the tongue anterior to improve laryngeal inlet visualization during FOI,3,4 some of these techniques may cause trauma to the tongue, bleeding into the airway, or both, further obscuring the operator's view during FOI.
Our patient received care at Shriners Hospitals for Children, and the parent of our patient provided written consent to medical photography and its use for treatment and educational purposes provided that the photo is modified and without patient identifiers. The patient was a 9-year-old child, weighing 34 kg, with limited mouth opening, and decreased temporomandibular joint movement due to severe orofacial burn and scarring. After induction of anesthesia, we were unable to obtain a clear view of the laryngeal inlet, and attempts at grasping the tongue with gauze to improve our view of the laryngeal inlet were unsuccessful. After 2 unsuccessful FOI attempts with conventional maneuvers by an experienced anesthesiologist, our anesthesia assistant (PM) made the unusual suggestion that we try using suction applied to the tongue as an alternative to grasping the tongue manually. The operating room suction tubing was applied to the tip of the tongue. A suction pressure of ∼120 mm Hg allowed us to displace the tongue anteriorly (Fig. 1), improving visualization of the epiglottis and the vocal cords and facilitating tracheal intubation. We did not observe any bruising or swelling of the tongue after this maneuver.
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Figure 1: Anterior traction of the tongue using a suction tubing apparatus during asleep flexible fiberoptic intubation in a pediatric patient.
Suction is readily available in the operating room and when applied to the tongue may serve as an adjunct for improving glottic exposure during asleep fiberoptic intubation in selected patients. Because there are no data other than our experience, it is possible that this maneuver could cause a tongue hematoma; thus some caution is warranted, but thus far we have not observed any adverse effects.
Adeniran A. Haastrup, MD
Pedro MendezCharles J. Cote, MD Department of Anesthesiology
Massachusetts General Hospital
Shriners Hospitals for Children
Harvard Medical School
Boston, Massachusetts
[email protected]
REFERENCES
1. Nandi PR, Charlesworth CH, Taylor SJ, Nunn JF, Doré CJ. Effect of general anaesthesia on the pharynx. Br J Anaesth 1991;66: 157–62
2. Durga VK, Millns JP, Smith JE. Manoeuvres used to clear the airway during fibreoptic intubation. Br J Anaesth 2001;87: 207–11
3. Witton TH. An introduction to the fiberoptic laryngoscope. Can Anaesth Soc J 1981;28:475–8
4. Childres WF. New method of fiberoptic intubation of anesthetized patients. Anesthesiology 1981;55:595–6
