General Articles: Case Report
Oral submucous fibrosis (OSMF) is a premalignant lesion of the buccal mucosa caused by chewing betel quid. It results in the progressive inability to open the mouth. Patients with OSMF require anesthesia for trismus correction, resection, and reconstructive (oncoplastic) surgery for coexisting oral malignancies or other unrelated surgeries. OSMF causes trismus, which results in difficulty in laryngoscopy and intubation of the trachea. The aim of this study was to review the airway management of patients with oral malignancies (n = 44) and describe the anesthetic management of patients with OSMF (n = 8).
After approval of the Institutional Research and Ethics Committee and written informed consent from the patients, anesthetic records of 44 patients with malignancies of the oral cavity were studied. All had undergone radical resections and reconstructive (oncoplastic) surgery in this hospital from July 2003 to May 2004.
All 44 patients had been diagnosed with squamous cell carcinomas (SCC) localized to the buccal mucosa (n = 23), lower alveolus (n = 9), and tongue (n = 12). These oral malignancies share similar risk factors. All patients but one gave positive history for the abuse of one of the three major risk factors identified: betel quid (n = 21), chewing tobacco (n = 6), and smoking (n = 16). OSMF was identified in 8 patients; all had limitation of mouth opening before the diagnosis of oral malignancy.
All the patients with OSMF were men between 35 and 60 yr of age. The abuse of betel quid was present in all 8, and 3 of them also smoked. The duration of abuse was variable from 5 to 25 yr. Most had continued to abuse betel quid despite the OSMF until the diagnosis of oral malignancy had been made. They were diagnosed to have SCC of the buccal mucosa (6 patients) and lower alveolus (2 patients). All lesions were on the left side (right-handed people usually place the quids in the left gingivobuccal sulcus). The clinical tumor stages (1) Tumor Node Metastasis (TNM) were T2 in one patient, T3 in 2 patients, and T4 in 5 patients, indicating a predisposition of OSMF-related malignancies to present later. Some patients felt that they would have presented earlier if they could have seen their oral cavity. Clearly, the trismus caused by the OSMF had delayed the diagnosis. Anesthetic evaluation included clinical airway examination. Interincisor distance (IID) and Mallampati score (2) were used to decide on the airway management. All patients with Mallampati score of 3 (n = 2) or less had successful tracheal intubation after direct laryngoscopy, whereas all those with Mallampati score 4 (n = 5) required fiberoptic intubation. One patient with a Mallampati score of 4 required tracheostomy as a result of an extensive tumor. Patients with OSMF had increased requirement for fiberoptic intubations; 62.5% (5 of 8) compared with 44.4% (16 of 36) of those with oral malignancies.
Three of the 8 patients with OSMF were chosen because each of their anesthetic managements was different. These are briefly mentioned. The fourth case of OSMF (not included in the above-mentioned series of 44 patients) was treated by an unconventional method and hence deserves mention.
A 40-yr-old 74-kg male with OSMF was diagnosed to have SCC of the buccal mucosa. The IID was 30 mm and Mallampati score 3. Anesthesia was induced with morphine 7.5 mg and propofol 150 mg IV with the patient spontaneously breathing halothane in a nitrous and oxygen mixture. “Preliminary laryngoscopy” was performed (Cormack and Lehane Grade 3) (3) and this prompted administration of vecuronium bromide 8 mg IV “Intubating laryngoscopy” was Grade 2 with external laryngeal manipulation and the trachea was successfully intubated with a lubricated 7.5 mm internal diameter Polar Preformed “Nasal North” Tracheal Tube (Portex Ltd. Hythe, Kent, UK) (PPNNTT).
A 35-yr-old 70-kg male presented with a 5-yr history of gradually diminishing ability to open his mouth and a painful ulcer in the mouth (SCC). His Mallampati score was 4 and IID was 10 mm. An awake fiberoptic intubation was planned and explained to him while consent for tracheostomy was also obtained. Using a combined local and regional anesthetic technique, the trachea was successfully intubated using a 7.5-mm inner diameter PPNNTT mounted on a fiberoptic bronchoscope.
A 45-yr-old 35-kg male presented with a large fungating tumor arising from his lower jaw that involved the cheek, lip, alveolus, floor of mouth, and tongue. He was malnourished (weight 35 kg) and anemic (hemoglobin 7g/dL), but his metastatic work up was negative. His airway assessment suggested no possibility of direct laryngoscopy and difficult fiberoptic tracheal intubation because of the tumor extent and previous irradiation (IID 5 mm and Mallampati score 4). He was scheduled to undergo a three-staged procedure (resection and two-stage reconstruction). In consultation with the surgeons and anticipating prolonged postoperative intensive care, an elective tracheostomy under local anesthesia was performed the day before surgery. He then underwent two surgeries, 3 wk apart, which were uneventful; he made remarkable recovery and awaits his final reconstruction when his nutritional status improves.
A 40-yr-old male presented with progressive inability in opening his mouth. He had fibrotic palpable plaques and leucoplakia on the buccal mucosa that was to be biopsied (Fig 1). His IID was 30 mm and Mallampati score 3. He was scheduled for an orthopedic external fixator (for gradually distracting his trismus), oral inspection, and biopsies. Anesthesia was induced with morphine 10 mg and thiopentone 300 mg (both IV) and tracheal intubation was facilitated by succinylcholine 75 mg IV. Direct laryngoscopy was grade 4, which improved to grade 3 with external laryngeal manipulation. The trachea was successfully intubated with considerable difficulty through the nasal cavity using a PPNNTT of 7.5 mm inner diameter. His oral lesions were biopsied and the external fixator was applied. His trachea was extubated at the end of the procedure and he made satisfactory recovery. His IID was gradually increased to 55 mm over 5 wk (weekly distraction of 5 mm) (Fig. 2). The histopathology was reported as negative for malignant change. The external fixator was removed and he was advised as to regular follow-up and strict abstinence from betel chewing.
OSMF is a precancerous condition of the upper airway that occurs in an estimated 2.5 million people worldwide (4). As evident from a report of OSMF in an 11-year-old in the United Kingdom (5), it may be a global problem. In Central, Southern, and Southeast Asia, the abuse of smokeless tobacco popularly involves the chewing of betel quid or “paan-supari.” This is a combination of betel or Areca nut (fruit of the Areca palm tree), betel leaf (Piper betel), tobacco, and slaked lime. The mixture is held adjacent to the buccal mucosa and slowly chewed over a long period of time (5). It produces effects similar to those of smoking tobacco and is addictive. OSMF typically affects the buccal mucosa, lips, retromolar areas, soft palate, and occasionally the pharynx and the esophagus. Early lesions appear as a blanching of the mucosa, imparting a mottled, marble-like appearance whereas later lesions demonstrate palpable fibrous bands that render the mucosa pale and thick and stiff (Fig 1). It results in progressive inability to open the mouth, pain, burning sensation, dysphagia, and hearing loss. The precancerous nature of OSMF and the reported occurrence of SCC in OSMF (2%–30%) (5) emphasize the importance of an earlier and more aggressive surgical approach toward OSMF and long-term follow-up on a regular basis.
Anesthesiologists should have a high degree of suspicion and carefully examine the airway of patients who abuse betel quid. The resulting trismus and IID has been used to classify patients into mild (IID >20 mm) and severe (IID <15mm) OSMF (6). This classification may be misleading for anesthesiologists, as IID of at least 30 mm is required for direct laryngoscopy (7) and patients with “mild OSMF” may still be difficult to intubate. “Preliminary laryngoscopy” under anesthesia is useful and should be reserved for patients with adequate mouth opening (Case 1). Airway management in OSMF depends on expertise and available equipment (9). Blind nasal or retrograde techniques may be used, although fiberoptic intubation is the technique of choice (Case 2). Tracheostomy under local anesthesia is to be resorted to if the former is unavailable or fails. If the oral malignancy is extensive or two-staged reconstruction is planned (Case 3), early tracheostomy may be indicated.
Other than trismus release or resection of oral malignancies, anesthesiologists may encounter patients with OSMF presenting for other surgeries. Unlike the unanticipated difficulty faced by Mahajan et al. (8), we categorize all patients who abuse betel quid as “anticipated difficult airways.” We also find that in OSMF, it is the trismus that causes the major difficulty in laryngoscopy and intubation. They (8) suggest indirect laryngoscopy in the preoperative evaluation of these patients. Although this may be useful in some cases, we find that the routine preoperative assessment of the airway (Mallampati score, thyromental distance, jaw subluxation, and neck flexion and extension) adequate in deciding the need for fiberoptic intubation. The clinical TNM also predicts difficulty in airway management, as those with advanced oral malignancies increasingly require fiberoptic intubations or tracheostomies.
The surgeons prefer the PPNNTT (Fig. 3), as they are secured to the forehead and remain out of the operating field. The radio opaque line must remain dorsal and cephalad; thus it cannot be rotated along its long axis on the fiberoptic bronchoscope. The preformed curve also makes it difficult to negotiate into the trachea, and suctioning the airway through them is also difficult. Reinforced tracheal tubes are better on both counts but are considerably more expensive.
In the first three cases described, OSMF contributed to the development of the malignancy, delayed the diagnoses, and complicated the anesthetic management. The fourth case demonstrates that an aggressive approach to OSMF provides good quality of life to the patient by improving oral hygiene and oral intake. This also obtains sufficient mouth opening, which is mandatory for follow-up and inspection of the remaining oral cavity (10).
This study also highlights the need for health education, public awareness campaigns, and legal or legislative action to ban the production and sale of betel quid. Anesthesiologists should be aware of this disease that is common in those who abuse betel quid.
The author acknowledges the contributions from Padhar Hospital of Rajiv Choudhrie, (Oncoplastic Surgeon and Head of Surgery), Dildeep Pillai, and Ashish Choudhrie (Onco-Surgeons), N. R. Padhi (Orthopedic Surgeon) and Thomas Samuel (Radiation Oncologist) in the conduct of the study and the preparation of the manuscript.
1. American Joint Committee on Cancer. Cancer Staging Manual, 6th ed. New York: Springer-Verlag, 2002:23–32.
2. Mallampati SR, Gatt SP, Guigino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985;32:429.
3. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984;39:1105–11.
4. Cox SC, Walker DM. Oral submucous fibrosis: a review. Aust Dent J 1996;41:294–9.
5. Shah B, Lewis MAO, Bedi R. Oral submucous fibrosis in an 11-year-old Bangladeshi girl living in the United Kingdom. Br Dent J 2001;191:130–2.
6. Merchant AT, Haider SM, Firkee FF. Increased severity of oral submucous fibrosis in young Pakistani men. Br J Oral Maxillofacial Surg 1997;35:284–7.
7. Stone DJ, Gal TJ. Airway management. In: Miller RD, ed. Anesthesia, 5th ed. Philadelphia: Churchill Livingstone, 2000:1414–51.
8. Mahajan R, Jain K, Batra YK. Submucous fibrosis secondary to chewing of quids: another cause of unanticipated difficult intubation. Can J Anaesth 2002;49:309–11.
9. Practice Guidelines for Management of the Difficult Airway. A report by the ASA Task Force on Management of the Difficult Airway. Anesthesiology 1993;78:597–602.
© 2005 International Anesthesia Research Society
10. Celik N, Wei FC, Chang YM, et al. Squamous cell carcinoma of the oral mucosa after release of submucous fibrosis and bilateral small radial forearm flap reconstruction. Plast Reconstr Surg 2001;107:1679–83.