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The intubating laryngeal mask for maxillo-facial trauma

Agrò, F.*; Brimacombe, J.; Brain, A. I. J.; Marchionni, L.§; Cataldo, R.

European Journal of Anaesthesiology: April 1999 - Volume 16 - Issue 4 - p 263-264
Case Report
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We report the successful use of the intubating laryngeal mask airway in a patient with maxillo-facial trauma for whom the facemask and laryngoscope were relatively contraindicated and the fibreoptic scope potentially difficult to use.

*Department of Anaesthesia, University School of Medicine LIU Campus Bio-Medico, Rome, Italy, †Department of Anaesthesia and Intensive Care, Cairns Base Hospital, Cairns, Australia, ‡Royal, Berkshire Hospital, Reading and Institute of, Laryngology, University of London, United Kingdom, §Department of Anaesthesia, Policlinico Universitario, Rome and Department of Anaesthesia, University School of Medicine LIU Campus Bio-Medico, Rome, Italy

Accepted June 1998

Correspondence: F. Agrò.

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Introduction

The intubating laryngeal mask (ILM) is a new airway device that facilitates blind or fibreoptic guided intubation while maintaining ventilation [1,2]. It was bioengineered using MRI scans of the adult upper airway and in theory has better intubation characteristics than the standard laryngeal mask airway (LMA)[1]. The principal new features are a short, wide bore, anatomically curved, rigid airway tube with an integral guiding handle and an epiglottic elevator bar replacing the mask aperture bars. It is supplied with a straight wire-reinforced silicone tracheal tube to optimize the intubation success rate and to reduce the risk of trauma. The device was designed for use in the neutral position, does not require insertion of the fingers into the mouth and does not require head/neck manipulation for placement or intubation. We would like to report the use of the ILM in a patient with maxillo-facial trauma for whom the facemask and laryngoscope were relatively contraindicated and the fibreoptic scope potentially difficult to use.

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Case report

A fit 18-year-old female, weight 50 kg, height 160 cm, presented for re-constructive surgery following maxillo-facial trauma 4 days previously. Her injuries included bilateral zygomatic arch fractures, oral-facial soft tissue oedema and lacerations, a naso-maxillary fracture, dental distortion and a possible cervical spine injury (neck pain, but no radiological bony injury) (Fig. 1). There was no intracranial or cardiothoracic injury and she was not at risk from gastric aspiration. Preoperative airway examination revealed mouth opening of 3 cm, a swollen lacerated tongue, displaced upper teeth and obstructed nares. Opening her mouth for examination precipitated fresh bleeding into her oral cavity. Her soft palate was not visible (Mallampati III), but her hard palate was intact and her airway was unobstructed. The patient refused awake intubation or a tracheostomy. She was therefore pre-oxygenated and induced with propofol 2.5 mg kg−1. A size 3 ILM was inserted easily using a one-handed rotational movement in the saggital plane with the mask following and firmly pressed into the arch of the palate and the posterior pharyngeal wall (Fig. 2). Once adequate ventilation was established, she was given vecuronium 0.1 mg kg−1. A lubricated size 7.5 straight silicone tracheal tube was passed blindly down the ILM and entered the trachea at the first attempt. The ILM was removed using a second smaller tracheal tube as a 'pusher' to prevent accidental extubation while the device was being withdrawn. Ventilation was continued throughout the intubation sequence. Surgery and anaesthesia were subsequently uneventful and the patient was extubated at the end of the 3 h procedure.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

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Discussion

Patients with maxillo-facial trauma can present a major challenge to the anaesthesiologist. Haemorrhage, haematoma, oedema, tissue distortion and associated neck injuries make conventional airway management difficult. The facemask and laryngoscope are relatively contraindicated because they can displace bony fragments, precipitate bleeding and often require head/neck manipulation for optimal performance. Fibreoptic intubation may be difficult/impossible due to bleeding and/or secretions. The standard LMA allows the patient to be ventilated during intubation attempts and protects the airway from oropharyngeal contamination [3], but insertion may be difficult in the neutral position [4], intubation is limited to a long, narrow bore tube, and head/neck manipulation may be required to direct the tube into the glottic inlet [5]. The ILM is a better option because it can be inserted in the neutral position, it facilitates the passage of a customized large bore, standard length tube and the guiding handle/rigid tube permits manipulation of the cuff within the pharynx, thus avoiding head/neck movement. One limitation of the technique is that the ILM cannot be inserted if the inter-dental distance is less than 20 mm (maximum outside diameter of the ILM).

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References

1 Brain AIJ, Verghese C, Addy EV, Kapila A. The intubating laryngeal mask. I: development of a new device for intubation of the trachea. Br J Anaesth 1997; 79: 699-703.
2 Brain AIJ, Verghese C, Addy EV, Kapila A, Brimacombe J. The intubating laryngeal mask. II: a preliminary clinical report of a new means of intubating the trachea. Br J Anaesth 1997; 79: 704-709.
3 John RE, Hill S, Hughes TJ. Airway protection by the laryngeal mask - a barrier to dye placed in the pharynx. Anaesthesia 1991; 46: 366-367.
4 Brimacombe J, Berry A. Laryngeal mask airway insertion. A comparison of the standard verses neutral position in normal patients with a view to its use in cervical spine instability. Anaesthesia 1993; 48: 670-671.
5 Lim SL, Tay DHB, Thomas E. A comparison of three types of tracheal tube for use in laryngeal mask assisted blind orotracheal intubation. Anaesthesia 1994; 49: 255-257.
Keywords:

intubating laryngeal mask; maxillo-facial trauma; difficult intubation

© 1999 European Academy of Anaesthesiology