Palatal pressure necrosis due to inappropriate size of Guedel's airway?

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Sir, A 40-year-old male weighing 63 kg presented to Emergency Department with alleged history of road traffic accident 2 days ago with altered sensorium and seizures, referred from a rural hospital. He had a Guedel's orophayrngeal airway size 4 (11 cm) (Romsons Scientific and Surgical Industries Pvt. Ltd., Agra, India) in situ firmly fixed with an elastic adhesive bandage. On initial assessment in the emergency scenario, the patient had a Glasgow Coma Score (GCS) of E3 V2 M5 with stable haemodynamics. A noncontrast computed tomography scan brain showed a left fronto-temporo-parietal subdural haematoma with underlying contusion with no mass effect and no evidence of any associated injuries. The patient was immediately shifted to our trauma Intensive Care Unit (ICU) for further management and monitoring. By the time patient reached the ICU, GCS deteriorated to E2 V1 M5 following a brief episode of seizure which lasted for 60 s. Hence, the decision was taken to perform rapid sequence induction using intravenous propofol (2 mg/kg) and injection rocuronium (1.2 mg/kg). On pulling out Guedel's airway to perform oral suctioning before intubation, it was noticed that the mucosa of the palatal region had undergone blackish discolouration apparently due to the sustained pressure of the Guedel's airway. However, the trachea was easily intubated with the appropriate size of the tracheal tube. In rural set ups such as ours, Guedel's airway is commonly available and used as a bite guard as well as for maintaining an open airway and it is made up of elastomeric or plastic material. However, the lack of awareness among primary health care providers can lead to fatal complications during airway management, especially during emergencies. Ideally, an appropriate size airway should relieve/prevent obstruction of the airway by preventing the tongue from falling back. Pressure necrosis of lower lip due to incorrect placement of Guedel's airway has also been reported.[1] The best criterion for proper size and position of the airway is an unobstructed gas passage. A method to ascertain the appropriate size of the airway by measuring the distance between the angle of mouth and mandible has been described.[2] Many primary care providers may not be aware of this. We also recommend that the manufacturers provide a diagrammatic depiction showing how to select proper size and insertion technique of airway on the package back cover to prevent such complications. In our case, palatal pressure necrosis may have occurred due to inappropriate size selection, prolonged placement and firm fixation of Guedel's airway with a tight elastic adhesive bandage. There is need to emphasize the importance of using proper size of airway devices and teaching the healthcare workers of correct usage of the devices available to them. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.