A reply

Abstract

Our expression of the neck position should have been more unambiguous. This ambiguity was due to a common practice of not distinguishing explicitly the position of the upper from lower cervical spine. We stated that ‘insertion of the conventional laryngeal mask is best achieved when the patient's neck is flexed and the head extended as described by Magill (‘sniffing’ position)’ [1]. This is the most commonly used expression of the head and neck position that Drs Brimacombe and Keller also adopt. A more accurate expression is extension of the occipitoatlantoaxial complex (i.e. extension of the head on the neck and of the upper cervical spine) and flexion of the lower cervical spine [2]. We also stated that ‘in fact, its insertion becomes more difficult or impossible when the patient's head and neck are in either the neutral or flexed position’ [1] and cited three articles [345]. In the first study [3], insertion of the laryngeal mask was more difficult when the occiput was placed directly on the trolley and the head and neck were stabilised (manual in-line position) than when the head and neck were placed in the Magill position. In retrospect, we should not have used the term ‘neutral position’, since it can be regarded as the position of the head and neck when the occiput is placed either directly on the trolley or on one pillow (or a pad). In the second study [4], it was suggested that flexion of both the occipitoatlantoaxial complex and lower cervical spine by cricoid pressure made insertion more difficult. In the third report [5], insertion of the mask was impossible when the occipitoatlantoaxial complex was flexed and the lower cervical spine extended. Drs Brimacombe and Keller state that we showed that neck flexion facilitated placement, but what we showed was that extension of the occipitoatlantoaxial complex (i.e. extension of the upper cervical spine) and flexion of the lower cervical spine facilitated placement [3]. Therefore, perhaps we should have stated that insertion may become more difficult when the occipitoatlantoaxial complex (or the head and upper cervical spine) is flexed. In our patient, both the occipitoatlantoaxial complex and the lower cervical spine were flexed due to burn contracture [1]. We expressed this as a ‘a fixed flexed neck’.