Letters to the Editor: Letters & Announcements
To the Editor:
A patient with amyoplasia congenita (1) and previous unsuccessful endotracheal intubation with standard/McCoy laryngoscopy, intubating laryngeal mask, and fiberoptic bronchoscopy, was scheduled for scoliosis correction. Simplified airway risk index score (2) amounted to 10 (Table 1). Preoperative magnetic resonance imaging (MRI) revealed long, counterclockwise-rotated, and left-shifted epiglottis, clockwise-rotated hyoid, and short epiglottis tip-to-retropharyngeal wall distance (Fig. 1); anatomic abnormalities were probably explanatory of preceding intubation failure (Fig. 1, see legend). Following anesthesia-induction, a number 4 McCoy blade carrying a 7F Fogarty catheter (Fig. 2A) (3) was introduced through left mouth corner and above the left molars (4). Blade-tip was directed posteromedially (4), epiglottis was visualized, and blade-tip was advanced deep into vallecula. The handle was rotated clockwise so that its convex surface was parallel to line AT of Figure 1B. Fogarty catheter balloon inflation (Fig. 2B), forceful laryngoscope elevation, and external thyroid pressure resulted in exposure of posterior glottis commissure. A gum elastic bougie was introduced into the larynx, and a 6.5-mm-internal diameter endotracheal tube passed over it into the trachea. Conclusively, combined sagittal and transverse upper airway MRI sections may aid in difficult airway management planning. Anatomic abnormality-associated difficulties with epiglottis lifting may be attenuated with “left molar” McCoy-balloon laryngoscopy.
Spyros D. Mentzelopoulos, MD, PhD, DEAA
Apostolos Armaganidis, MD, PhD
Dimitra Niokou, MD
Paraskevi Matsota, MD
Maria Tzoufi, MD, DEAA
Nikos Kelekis, MD, PhD
Kostantinos Soultanis, MD, PhD
Nikos Oikonomopoulos, MD
Georgia Kostopanagiotou, MD, PhD
Departments of *Intensive Care Medicine, †Anesthesiology, ‡Radiology, and §Orthopedic Surgery
Attikon University Hospital
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4. Yamamoto K, Tsubokawa T, Ohmura S, et al. Left-molar approach improves the laryngeal view in patients with difficult laryngoscopy. Anesthesiology 2000;92:70–4.