[Unexpectedly complicated laryngoscopy caused by a massive mandibular tori].

Here, we report a case of an unexpectedly complicated laryngoscopy caused by massive mandibular tori. A 64-year-old man with mitral regurgitation and aortic regurgitation was scheduled for a double valve replacement. Thyromental distance and the Mallampati score were used as predictive factors of difficult intubation, and both factors were within the normal range. Anesthesia with controlled ventilation was started with fentanyl, propofol and vecuronium. After the attainment of full muscle relaxation, an experienced anesthesiologist performed direct laryngoscopy. It was not possible to intubate the patient under direct laryngoscopy because of massive mandibular tori which had not been detected prior to induction. Following the failure of direct laryngoscopy, a McCoy laryngoscope and a gum elastic bougie were deployed to improve vision. Intubation with a 7.5 mm tube was successful at the third attempt. We hope our experience will serve as a reminder to clinicians that mandibular tori, although benign and without subjective symptoms, could have significant effects upon direct laryngoscopy by compromising the line of vision. Preoperative oral evaluation is critical and aggressive treatment should be considered.

[Brachial plexus neuropathy following open-heart surgery].

A 64-year-old woman underwent open-heart surgery for repair of atrial septal defect (ASD) and tricuspid valve regurgitation. Preoperative complications included rheumatoid arthritis with pain in both wrists treated with methotrexate. Following smooth endotrachial intubation, a pulmonary arterial (PA) catheter was inserted into the right jugular vein after several attempts. She was placed in a supine position with abduction of the shoulders to approximately 90 degrees and of the elbows to 60 degrees. Operation was performed through sternum splitting to second intercostal space, and the 4-h intraoperative course was uneventful. On the first postoperative day, she complained of inability to raise her right arm. Neurological examination revealed marked weakness of the deltoid and biceps brachialis muscles, and decreased sensitivity around the right shoulder. Iatrogenic brachial plexus injury was diagnosed. Administration of vitamin B12 and physical therapy were instituted. Symptoms improved gradually and had disappeared by 3 months postoperatively. Neuropathy might be attributed to stretch and compression of the brachial plexus caused by traction of the pectoralis minor muscle enhanced by sternotomy and/or malposition of the upper extremity, or direct injury due to cannulation of the PA catheter into the internal jugular vein.