Right molar approach to tracheal intubation in a child with Pierre Robin syndrome, cleft palate, and tongue tie
New Delhi, India
* E-mail: kirtinath{at}gmail.com
Editor—The right molar approach for laryngoscopy has been described for intubation of patients with a difficult airway as the paraglossal1 and retromolar2 technique, respectively. In this technique,1 a straight blade laryngoscope is introduced from the right corner of the mouth along the groove between the tongue and the tonsil, using leftward and anterior pressure to displace the tongue to the left of the laryngoscope. The blade is advanced and its tip is made to pass posterior to the epiglottis. Rotation of the neck and manipulation of the cricoid cartilage have been suggested to improve the laryngoscopic view.2 The advantage of using this technique is that structures in the midline which hamper the laryngeal view in the anterior airway line3 are avoided. We used this technique to successfully intubate a child with Pierre Robin syndrome, cleft palate, and tongue tie. These children are known to have airway obstruction due to the distorted anatomy and are difficult to mask ventilate and intubate. Reduced tongue mobility has been identified as an independent factor for difficult intubation4 in five adult patients with reduced tongue mobility who required fibreoptic or retrograde intubation. A combination of cleft palate with tongue tie has been reported to cause problems in intubation which was accomplished by the two anaesthetist technique.5
A 14-month-old male was scheduled to undergo cleft palate repair. On examination, he had a micrognathic mandible and tongue tie. Anaesthesia was induced with oxygen, nitrous oxide, and sevoflurane using a paediatric breathing circuit with mask and end-tidal capnography, pulse oximetry, and cardiac monitor and an i.v. cannula was commenced. As the depth of anaesthesia increased, signs of airway obstruction appeared, but after a Guedel airway was inserted, there were no problems in maintaining the airway or ventilating the lungs. Glycopyrrolate, meperidine, and succinylcholine were given i.v. Laryngoscopy was performed after adequate positioning with a straight blade (Miller) laryngoscope but no laryngeal structure, including the epiglottis, could be seen even after optimum external laryngeal manipulation (OELM). A single blind attempt at intubation with a south pole RAE tube, size 4.5 with a stylet inserted into it, and shaped into a curve with a hockey stick end resulted in oesophageal intubation. The tube was withdrawn and the patient ventilated with the mask. As the patient had three anatomical airway problems in the midline, it was decided to perform laryngoscopy by the right molar approach. The laryngoscope was re-introduced through the right angle of the mouth and the tip was directed to the midline into the valleculla. OELM was applied and this brought the posterior rim of the glottis into view, although no other laryngeal structure was visible. Intubation was accomplished successfully on the first attempt.
References
1 Henderson JJ. The use of paraglossal straight blade laryngoscopy in difficult tracheal intubation. Anaesthesia (1997) 52:552–60.[CrossRef][Web of Science][Medline]
2 Bonfils P. Difficult intubation in Pierre-Robin children, a new method: the retromolar route. Anaesthetist (1983) 32:363–7.[Web of Science][Medline]
3 Marks RRD, Hancock R, Charters P. An analysis of laryngoscope blade shape and design: new criteria for laryngoscope evaluation. Can J Anaesth (1993) 40:262–70.[Web of Science][Medline]
4 Rosenstock C, Kristensen MS. Decreased tongue mobility—an explanation for difficult endotracheal intubation? Acta Anaesth Scand (2005) 49:92–4.[CrossRef][Web of Science][Medline]
5 Jones SE, Derrick GM. Difficult intubation in an infant with Pierre Robin syndrome and concomitant tongue tie. Pediatr Anaesth (1998) 8:510–1.[CrossRef][Web of Science][Medline]
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