Difficult Endotracheal Intubation Due to Unrecognized Dysfunction of Temporomandibular Joint: A case report / 대한구급학회지

In association with facial trauma, fracture of mandibular condyle occurs frequently. From that injury, the dysfunction of temporomandibular joint and the following limitation of mouth opening causing difficult intubation can result. So the anesthesiologists should have the capability of recognizing such problems. But in the case of facial trauma, pain and muscle spasm also cause similar but reversible conditions posing difficulty in differential diagnosis. In this case the patient showed some degree of limitation in mouth opening (1 finger breath) at the preoperative evaluation, so the author performed routine induction expecting the occurrence of full mouth opening after muscle relaxation. But the patient's mouth couldn't be opened any further and the exposure of epiglottis was impossible. Now since we have no reliable predictive criteria of irreversible temporomandibular joint dysfunction, awake fiberoptic intubation should be strongly considered in the case of condylar fracture with any limitations in mouth opening.

The Development of an Inspiratory Time Adjustable Transtracheal Jet Ventilator and Evaluation in a Human Adult Trachea-Lung Model / 대한마취과학회지

BACKGROUND: Transtracheal jet ventilation (TTJV) has been used for 'Cannot Ventilate/Cannot Intubate' situation, lefe-saving situations, by simply introducing an IV catheter (angiocatheter) through the cricothyroid membrane. To decrease the occurrence of barotrauma caused by a continuous high pressure oxygen supply while applying TTJV, it would be ideal to have a TTJV system equipped with an inspiration time adjustable function which any currently commercially available TTJV does not have. METHODS: Recently, we made a prototype of an inspiration time adjustable TTJV and measured the corresponding injection volumes and peak inflation pressures according to the changes of oxygen supply pressure and inspiration time using catheters ranging from 14 to 20 G in a simulated human adult trachea-lung model. RESULTS: A 16 G angiocatheter provided 465 +/- 5 ml of injected volume with a peak inflation pressure of 25 cmH2O under a 50 psi oxygen supply at 1 second of inspiration, which would be adequate for an adult tidal volume. When a 14 G catheter was used under the same conditions as above, the injected volume was 1128 +/- 9 ml. All injected volumes were under 310 ml when 18 and 20 G angiocathers were used at variosus driving pressures (10 - 50 psi) and inspiration time (0.5, 0.75, and 1 s). CONCLUSIONS: An inspiration time adjustable TTJV can easily provide enough tidal volume to maintain oxygenation, and could be expected to prevent or reduce barotraumatic complications such as pneumothorax.

The Two Step Fiberoptic Approach in the Management of a Difficult Pediatric Airway due to a Vallecular Cyst / 대한마취과학회지

A 6-yr-old male weighing 20 kg with the diagnosis of a large vallecular cyst in the oropharynx was scheduled for surgical excision. After a slight loss of consciousness following an IV injection of ketamine 10 mg while maintaining spontaneous respiration, 4% lidocaine was sprayed into the right nostril. An uncuffed 4 mm OD wire-reinforced endotracheal tube was advanced through the right nostril and positioned in the nasopharynx. An ultrathin 60 cm Olympus LF-P fiberoptic bronchoscope (OD: 2.2 mm) was threaded and the vocal cords and surrounding structures were identified as intact. The endotracheal tube and fiberscope were withdrawn. Ketamine 10 mg was injected intravenously again. Following direct insertion of an Olympus fiberoptic bronchoscope (OD: 3.8 mm) through the right nostril without tube placement and visualization of the vocal cords, topical anesthesia of the larynx was achieved by spraying 1 ml 2% lidocaine through the biopsy channel. Thirty seconds later, it was passed into the trachea and 1 ml 2% lidocaine was sprayed intratracheally. The bronchoscope was withdrawn. The 4 mm uncuffed wire-reinforced tube was passed again through the right nostril and an ultrathin fiberoptic bronchoscope (OD: 2.2 mm) was threaded over the tube, and passed smoothly without resistance. There was neither laryngeal spasm nor cough. Anesthesia was maintained with enflurane 2.0 vol%, N2O (1.5 L/min) and O2 (1.5 L/min). The mass was successfully excised and extubated without compromise. The patient was uneventfully discharged the next day.

The Experiences of Airway Management for Anesthesia of Patients with Involved Cervical Spine Ankylosing Spondylitis / 대한마취과학회지

Ankylosing spondylitis is a chronic and systemic disease involving the axial skeleton. In patients with involved cervical spine ankylosing spondylitis, endotracheal intubation by direct laryngoscope may be difficult because they have a limitation of cervical movement and anatomical anomalies. We experienced the evaluation of thirteen patients with involved cervical spine ankylosing spondylitis by the Mallampati classification, Cormack and Lehane grade, thyromental distance and orolaryngeal angle. By Mallampati class and Cormack and Lehane grade, patients were almost class 3 or 4. Thyromental distance was 5.3 +/- 0.4 cm, and orolaryngeal angle was 90.4 +/- 8.0o.

Pneumothorax and Pneumomediastinum Occurred after Esophageal Perforation by a Stylet during Difficult Endotracheal Intubation / 대한마취과학회지

Pneumothorax and pneumomediastinum can occur spontaneously, secondary to trauma, or from dissection of air from the neck or retroperitoneal space. The most common cause of traumatic pneumomediastinum is a rupture of the esophagus, which can occur during an episode of severe vomiting or, less frequently, following esophageal instrumention. We experienced a case of pneumothorax and pneumomediastinum, developed after esophageal perforation by stylet during difficult endotracheal intubation even though an esophagogram did not reveal the perforation site.

Intubating Layngeal Mask Airway in Awake Intubation / 대한마취과학회지

The incidence of difficult intubation varies from 1.5% to 13%, and failed intubation has been identified as one of the anesthesia-related causes of death or permanent brain damage. The Intubating Laryngeal Mask Airway (ILMA) is a new modified laryngeal mask airway with the capability for guided tracheal intubation while maintaining ventilation. The ILMA was designed to improve blind endotracheal intubation through a laryngeal mask airway. It does not require head and neck manipulations on insertion. The success rate of blind intubation using the ILMA was up to 99.3% in patients with or without airway problems. We experienced two cases of the difficult endotracheal intubation due to cervical spine 1 2 fractured 34 years old female patient and cervical spine 5 6 fractured 62 years old female patient were done successful awake airway management through the ILMA with superior laryngeal nerve block with pharyngeal and endotracheal topical spray of lidocaine. These cases suggest that awake tracheal intubations through the ILMA is a safe and useful method for airway management in anesthetic care of cervical spine fracture patients.

A Endotracheal Intubation in a Child with Mocopolysaccharidoses Using the Fiberoptic Laryngoscopy / 대한마취과학회지

Mucopolysaccharidoses are a group of inherited disorders of metabolism resulting in the deposition of mucopolysaccharide in various tissues. This leads to organ dysfunction and anatomical abnormalities which can be important to the anesthetist. These abnormalities result in airway difficulty and difficult intubation. We successfully performed endotracheal intubation in a case of mucopolysaccharidoses in a 9-year-old female patient using fiberoptic laryngoscopy.

Evaluation of Predictive Factors for the Difficult Intubation in Pregnant Women / 대한마취과학회지

BACKGROUND: Difficult tracheal intubation during anesthetic induction can be a lifethreatening situation, especially in pregnant women. This is the leading cause of anesthetic related maternal mortality. The ability to predict such cases preoperatively would be of great value. We conducted a prospective study to investigate the incidence of difficult intubation and the usefulness of various predictive factors for difficult intubation in pregnant women. Metoods: Predictive studies on three hundred nine pregnant women who underwent general anesthesia and tracheal intubation for an elective caesarean section were conducted using airway measurements such as a modified Mallampati classification (m-MP), interincisor gap (IG), thyromental distance (TMD), and sternomental distance (SMD). Then direct laryngoscopic gradings (LG) and difficult intubation (DI) were determined. All patients were evaluated on the basis of these studies, and the sensitivity, specificity, positive and negative predictive values (PPV, NPV) of each study were calculated. RESULTS: DI was observed in 5 patients (1.62%) and failed intubtion was observed in 1 patient (0.32%). The sensitivity and specificity of the m-MP were 80% and 82% respectively, and those of the IG were 80% and 77% respectively. A combination of the m-MP and IG resulted in high sensitivity and specificity (100% and 76% respectively), but low PPV (5%). CONCLUSIONS: This study concluded that m-MP and IG were the most sensitive and specific tests when used alone or in combination.

Total Intravenous Anesthesia for Freeman-Shelden Syndrome / 대한마취과학회지

Freeman-Sheldon syndrome (FSS) is a rare congenital myopathy and dysplasia characterized by a whistling mouth and hand-foot anomalies. There are several anesthetic challenges like difficult airway and intravenous access, and the possibility of malignant hyperthermia. We controlled the anesthetic management of a patient with FSS undergoing contractured thumb correction. Intubation was done with a tracheal tube by direct laryngoscopy after three failed attempts. An anesthetic technique triggering malignant hyperthermia was not used. Anesthetic agents used were ketamine, propofol, fentanyl and nitrous oxide under spontaneous respiration. The child had an uneventful anesthetic course and no sign or symptoms of malignant hyperthermia.

Difficult Endotracheal Intubation by Airway Trauma / 대한마취과학회지

We report a case of unsuspected difficult intubation in an adult due to anatomical abnormalities caused by a thermal burn injury on the right anterior pillar of the pharynx. After induction of anesthesia, vocal cords and epiglottis were not seen and the right half of the pharyngeal cavity was obstructed by a narrowed palatoglossal arch on the laryngoscopic view. Endotracheal intubation trials failed by oral and nasal routes. The laryngeal mask airway could not be passed into the narrowed oropharynx. We awaked the patient and took the patient's past history precisely and an otolaryngologic evaluation was taken. We found that at the age of six, the patient experienced a thermal burn injury on the right anterior pillar of the pharynx by heated iron and anatomical deformities by scar contracture formed thereafter. The next day a partial palatoglossal resection was done in sitting position under local anesthesia and then endotracheal intubation by direct laryngoscopy could be completed successfully.

The Predictors of Difficult Tracheal Intubation can Predict Difficult Mask Ventilation / 대한마취과학회지

BACKGROUND: Unexpected failed mask ventilation can result in brain damage or death. The purpose of this study was to demonstrate that the tests for predicting difficult tracheal intubation can be used to predict difficult mask ventilation in Koreans. METHODS: One hundred ninety one patients were assessed before operation using the modified Mallampati test and by measuring the atlanto-occipital angle (AOA), thyromental distance (TM), hyomental distance (HM), sternomental distance (SM), and horizontal length of mandible (HLM). The mask ventilation grades and the laryngeal grades were determined. The sensitivities, specificities and positive predictive values of tests were calculated. RESULTS: Eleven patients (5.7%) had difficulty in mask ventilation and 8 patients (4.1%) had difficulty in intubation. AOA grade had the highest sensitivity and every tests had relatively high specificities for predicting difficult mask ventilation. CONCLUSIONS: The tests for predicting difficult tracheal intubation can be used to predict difficult mask ventilation.

Nasotracheal Intubation Using Fiberoptic Bronchoscope and Guidewire in a Pediatric Mandibular Fracture Patient: A case report / 대한마취과학회지

Although the endotracheal intubation using laryngoscope can usually be performed under general anesthesia, it may be very difficult in situations such as head and neck trauma, hemorrage, or deformity. Recently we performed antegrade fiberoptic nasotracheal intubation with a guide wire. A 15-month aged female child with mandibular fracture was scheduled for open reduction and internal fixation under general anesthesia. She was anticipated difficult intubation due to displacement of the fracture site. After induction of anesthesia, we passed an adult fiberoptic bronchoscope (O.D. 3.8 mm, LF-2, Olympus optical co, Japan) to vocal cord via right nostril. Then a guidewire was inserted through the suction port of bronchoscope, and bronchoscope was removed in a state of guidewire in situ. We slid the endotracheal tube over guidewire according to Seldinger's technique. We think that nasotracheal intubation using an adult fiberoptic bronchoscope and a guidewire is good for children under 2 years old who are expected the difficult intubation.

The Effects of the Levering Laryngoscope on the Laryngoscopic View / 대한마취과학회지

BACKGROUND: The effects of the levering laryngoscope (McCoy laryngoscope) on the laryngoscopic view classified by the Cormack and Lehane were investigated in this study. METHODS: The laryngoscopic view with the levering laryngoscope blade in neutral and best position were recorded respectively and analysed statistically. RESULTS: 109 laryngoscopic views were grade 1 or 2 and 12 were grade 3 or 4 in the neutral position with the McCoy blade. Only three patients were grade 3 or 4 in its best position and the others grade 1 or 2. The reduction in the incidence of difficult laryngoscopic view (grade 3 or 4) using the levering laryngoscope in its best position was statistically significant (p<0.01). CONCLUSIONS: Levering laryngoscope improves laryngoscopic view and also reduces the incidence of difficult intubation. So, we suggest that it is an useful instrument for the anesthesiologists in the difficult tracheal intubation.

Freeman-Sheldon Syndrome: Difficult Intubation A case report / 대한마취과학회지

The Freeman-Sheldon syndrome (FSS) is a rare congenital myopathy. Main manifestations are "whistling face", camptodactyly with ulnar deviation of the finger and talipes equinovarus. Myopathic fibrotic circumoral musculature result in microstomia with the characteristic protruding pursed "whistling lip" and mandibular and laryngeal development may also be abnormal. Thus the patients with FSS are expected to difficult intubation and the use of muscle relaxant should not be expected to improve intubating condition. We report a children with the Freeman-Sheldon syndrome who was intubated with fiberoptic laryngoscope and discuss anesthetic consideration.

Anatomical Factors to Discriminate Difficult Tracheal Intubation in Micrognathia / 대한마취과학회지

BACKGROUND: Micrognathia is the prime, constant bony finding that signals trouble for access to the airway. Anatomical factors of difficult tracheal intubation in micrognathia have been evaluated. METHOD: Forty one patients with micrognathia were divided into 3 groups based on modified Mallampati classification. Lateral cephalometric view taken preoperatively was used to measure 13 anatomical factors. Kruskal-Wallis test and discriminant analysis were used to select the most predictable factors for distinguishing between the difficult and easy groups. RESULTS: The most discriminating factors are mandibulo-hyoid distance(V12), atlanto-occipital distance(V10) and mentum-hyoid distance(V11). The discriminant analysis using above 3 factors gives the following discriminant functions(Y1= 0.7924(V12) - 0.2154(V10) - 0.3531(V11) (discriminant function 1), Y2= -0.2177(V12) + 0.8221(V10) -0.6304(V11) (discriminent fuction 2)) and the discriminating power of difficult intubation is 72.9%. CONCLUSIONS: Modified Mallampati classification and lateral cephalometric assessment of 3 anatomical factors can predict the difficult intubation.

The Estimate of Difficult Endotracheal Intubation / 대한마취과학회지

BACKGROUND: Endotracheal intubation is accomplished for safe airway establishment, anaesthesia and operation in operating room, intensive care unit and emergency room mostly. Therefore, it will be beneficial that we predict and provide against difficult airway. With this view, our study was planned and carried out. METHODS: For 251 patients with ASA physical status I or II undergoing general aneathesia, the correlation between their age, sex, height, weight, BMI (body mass index), Samsoon & Young classification and laryngoscopic grades by Cormack & Lehane was investigated. RESULTS: Laryngoscopic grades were correlated significantly with patients' age and Samsoon & Young classification. Endotracheal intubation succeeded all, but, 8 patients (3.2%) were difficultly intubated with cricoid cartilage compression and stylet-using. CONCLUSIONS: Before intubating the trachea, it is desirable that patient' age, Samsoon & Young classification and the extent of neck's movement are assessed.

Use of LMA as a Conduit of Endotracheal Tube for Difficult Tracheal Intubation with the Aid of Fiberscope Attached to the Video-Camera System: A case report / 대한마취과학회지

The incidence of airway difficulty in the general surgical population varies greatly depending on the degree of airway difficulty. Much of the anesthesia related morbidity attributable to managing a difficult airway comes from an interurruption of gas exchange (hypoxia and hypercarbia) which may cause cardiovascular instability and brain damage. Most airway catastrophes ocurrs when possible difficulty with the airway was not recognized. Although fiberoptic intubation is reliable method in patients with difficult airways, there are many cases of difficulty in visualizing the structure of the larynx with conventional fiberoptic technique due to copious secretion, swelling and hemorrhage in the pharyngeal cavity. Recently, we experienced a success in difficult tracheal intubation with LMA in the 27 year old male patient diagnosed ankylosing spondylitis. We hope that using a #4 LMA as a conduit for 6.0 mm cuffed endotracheal tube with the aid of fiberscope attached to the video camera system would be an alternative method for difficult intubation.