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MRI of the Upper Airway and McCoy-Balloon Laryngoscopy with Left Molar Approach in a Patient with Arthrogryposis Multiplex Congenita and Previous Unsuccessful Endotracheal Intubation

Mentzelopoulos, Spyros D. MD, PhD, DEAA*; Armaganidis, Apostolos MD, PhD*; Niokou, Dimitra MD; Matsota, Paraskevi MD; Tzoufi, Maria MD, DEAA*; Kelekis, Nikos MD, PhD; Soultanis, Kostantinos MD, PhD§; Oikonomopoulos, Nikos MD; Kostopanagiotou, Georgia MD, PhD

doi: 10.1213/01.ANE.0000139735.87434.71
Letters to the Editor: Letters & Announcements
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SDC

Departments of *Intensive Care Medicine, †Anesthesiology, ‡Radiology, and §Orthopedic Surgery; Attikon University Hospital; Athens, Greece; sdm@hol.gr

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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.

Table 1

Table 1

Figure 1

Figure 1

Figure 2

Figure 2

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

Athens, Greece

sdm@hol.gr

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References

1. Alfonso I, Papazian O, Paez JC, Grossman JA. Arthrogryposis multiplex congenita. Pediatr Intern 2000;15:197–204.
2. El-Ganzouri AF, McCarthy RJ, Tuman K, et al. Preoperative airway assessment: predictive value of a multivariate risk index. Anesth Analg 1996;82:1197–204.
3. Mentzelopoulos SD, Rellos KV, Magoufis GL, et al. Combined McCoy and balloon laryngoscopy for the emergency airway management of a patient with acute postoperative airway obstruction due to extreme engorgement of the tongue [letter]. Anesth Analg 2003;96:1531.
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.
© 2004 International Anesthesia Research Society