Cannot ventilate, difficult to intubate

Abstract

Editor: A 57-yr-old (90 kg) male was scheduled to undergo a left orbit osseointegration procedure for attachment of a facial prosthesis. He had previously undergone a craniofacial resection for squamous cell carcinoma of the left ethmoid sinus with exenteration of the left orbit followed by a course of radiotherapy. The pre-anaesthetic evaluation of this patient was unremarkable apart from some limitation of mouth opening. He had a grommet insertion under general anaesthesia 3 months before but no records were available. Since his previous surgeries were apparently uneventful, it was decided to anaesthetize this patient using total intravenous anaesthesia with muscle relaxant. Because of the anticipated duration of surgery (>3 h) endotracheal intubation was planned. The patient was routinely asked to give consent for the use of his photographs for teaching and research purposes as well as for publications. In the theatre after monitoring was instituted, the patient was pre-oxygenated, given 3 mg of midazolam as a premedicant and target-controlled infusions of propofol and remifentanil infusions were commenced. It became apparent that we were unable to ventilate this patient with a face mask because of the facial defect and the removal of the orbital floor. A size-5 laryngeal mask was inserted through which ventilation was easy. Atracurium 45 mg was then given. On direct laryngoscopy we could not visualize the epiglottis. Attempts with a McCoy blade and blind bougie insertion also failed, although oxygenation and ventilation with the laryngeal mask was well maintained when reinserted. The patient's airway was secured by asleep fibre-optic nasal intubation with a 7.0 reinforced tracheal tube that was clearly visible through the orbital defect (Fig. 1). The surgery proceeded smoothly and the patient was extubated uneventfully.Figure 1.: Tracheal tube seen through the open orbit.Discussion Anaesthetists may find it difficult or impossible to face-mask ventilate such patients where the orbital floor has been removed. Endotracheal intubation may also be difficult because of altered anatomy as a result of previous surgery and the effects of radiotherapy. Awake trans-orbital intubation, fibre-optic trans-orbital intubation [1,2], the use of lighted stylets and tracheotomy have all been reported in the airway management of similar cases, especially in patients with scarring of the face and limited mouth opening. However, in our case a trans-orbital tube would have made the surgery difficult. In this case, awake fibre-optic intubation would have been the safest method of airway management.