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References 1.
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SchiebleT, Patel A, Davidson M. Laryngeal mask airway (LMA) artifact resulting in MRI misdiagnosis. Pediatr Radiol 2008;38:328-30. Langton JA, Wilson I, Fell D. Use of laryngeal mask airway during magnetic resonance imaging. Anaesthesia 1992;47:532. LMATM Airway Inst ruction Manual. San Diego: LMA North America Inc.; 2005. Jolliffe L, Jackson I. Airway management in outpatient setting: New techniques and devices. Curr Opin Anaesthesiol 2008;21:719-22. Singh I, Gupta M, Tandon M. Comparison of clinical performance of i-gelTM with LMA- ProsealTM in elective surgeries. Indian J Anaesth 2009;53:302-5. Bopp C, Carrenard G, Chauvin C, Schwaab C, Diemunsch P. The I-gel in paediatric surgery: Initial series. American Society of Anesthesiologists (ASA) Annual Meeting; New Orleans, USA, October 17-21 2009 A 147.
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DOI: 10.4103/0970-9185.94917
Mallampatti class 4 to class 1!! Sir, A ranula is a retention cyst filled with mucus, occurring as a result of the blockage of a sublingual salivary gland or unnamed glands in the oral cavity.[1] Plunging ranulas associated with or without oral swellings can burrow into the submandibular, submental, and retropharyngeal spaces, lateral aspect of neck, and upper mediastinum. They are usually asymptomatic but rarely cause dysphagia and potential airway obstruction.[2,3] A 4-year-old boy presented with a history of swelling in the sublingual region gradually increasing in size since 3 years. The patient had difficulty in eating solid food, the mouth was always kept open, and there was excess salivation. On examination, a swelling measuring 5 × 4 cm was seen in the sublingual region extending more to the left side and pushing the tongue into the oral cavity and leaving the mouth open. Airway examination revealed the tongue almost covering the entire oral cavity making the uvula with palatal arch not visible and it graded as a Mallampatti class 4 airway The thyromental distance could not be measured correctly because 264
the swelling was in the submandibular and submental regions. The child was apparently healthy with no respiratory distress and systemic disorders. The child was scheduled for excision of the cyst. After premedication with atropine 0.4 mg and midazolam 1 mg intravenously (IV), through an IV cannula in situ, the child was shifted to the operating room. Standard monitors were connected and anesthesia was induced with thiopentone. Suxamethonium administered after confirming adequacy of ventilation. Oral tracheal intubation was planned as difficulty in visualization of vocal cords was anticipated. The vocal cords were not visible on direct laryngoscopy with help of a size 2 Macintosh (MAC) blade. As the blade was swept over the tongue, the tip of the blade could not be manipulated into the vallecula beyond the swelling. The tip of the blade could be manipulated beyond the swelling to visualize the posterior commissures of the cords, with an external laryngeal pressure, when an MAC 3 adult-sized blade was used. An uncuffed 5-mm ID endotracheal tube (ETT) with stylet was passed through the vocal cords with difficulty in the second attempt [Figure 1]. We decided to secure the ETT using the nasal route as there was concern of tube coming in surgical field and accidental tracheal extubation during surgical manipulation. Aspiration of the 50 ml of fluid from cyst was done. The swelling was reduced sufficiently in size [Figure 2]. Laryngoscopy was attempted with MAC 2 blade and this time the vocal cords were easily visible (Cormack and Lehanne grade 1) without any external manipulation. Nasal intubation was carried out easily with a 4.5-mm ID uncuffed ETT and the throat packed. Marsupialization of the cyst was done. Tracheal extubation was uneventful. Surgical management is preferred for most ranulas. Marsupialization is done preserving the sublingual gland and
Figure 1: Lateral profile after oral intubation showing swelling in mandibular region
Journal of Anaesthesiology Clinical Pharmacology | April-June 2012 | Vol 28 | Issue 2
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Maxillofac Surg 1995;53:280-3. Potdar M, Patel RD, Dewoolkar LV. Molar Intubation for Intra Oral Swellings: Our Experience. Indian J Anaesth 2008;52:861. Access this article online Quick Response Code:
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DOI: 10.4103/0970-9185.94918
Figure 2: Aspiration of the cyst after intubation
adjacent tissue.[4] Molar intubation or paraglossal techniques, requiring expertise, are advocated when standard laryngoscopy as a large tongue remains anterior to the blade due to a large infraoral swelling.[5] Use of an MAC 3 adult blade in young children in these situations is required to go beyond the swelling up to the base of the tongue into the vallecula and visualize the epiglottis and then the glottis. In close consultation with the surgical colleague, the feasibility of aspiration of the cystic lesions should be considered, if does not interfere with the plane of dissection. For safe airway management in selective cystic lesions, particularly in the absence of availability of difficult intubation aids, the cyst can be aspirated before tracheal intubation. Rohith Krishna, Murugesh Wali1, Madagondapalli Srinivasan Nataraj, Thrivikram Shenoy Department of Anaesthesiology, Kasturba Medical College, Manipal, Manipal University, 1Narayana Hrudayalaya, Bangalore, Karnataka, India Address for correspondence: Dr. Rohith Krishna, Department of Anaesthesiology, Kasturba Medical College, Manipal University, Manipal – 576104, India. E-mail:
[email protected]
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Baurmash HD. Mucoceles and ranulas. J Oral Maxillofac Surg 2003;61:369-78. Horiguchi H, Kakuta S, Nagumo S. Bilateral plunging ranula. A case report. Int J Oral Maxillofac Surg 1995;24:174-5. Shelley MJ, Yeung KH, Bowley NB, Sneddon KJ. A rare case of an extensive plunging ranula: Discussion of imaging, diagnosis, and management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:743-6. Yoshimura Y, Obara S, Kondoh T, Naitoh SI, Schow SR. A comparison of three methods used for treatment of ranula. J Oral
Effect of intraoperative depth of anesthesia on postoperative pain and analgesic requirement: A possible misidentified role of propofol Sir, We read with interest the article “Effect of intraoperative depth of anesthesia on postoperative pain and analgesic requirement: A randomized prospective observer blinded study” by Sahni et al.[1] The authors compared two groups of patients both anesthetized with standardized isoflurane and nitrous oxide anesthesia, in one group supplemental propofol boluses were administered in order to maintain bispectral index (BIS) between 40 and 45. As rescue analgesic requirement was lower in the group with the lower BIS, the authors concluded that maintaining BIS to a value of 45–40 throughout the surgery results in better postoperative pain relief. However, to draw their conclusions, the authors did not take into consideration the difference in the total amount of propofol administered, which was statistically larger in the group with the lower BIS. Cheng et al.[2] showed that general anesthesia with propofol is associated with less postoperative pain and morphine use than the general anesthesia with isoflurane. The lesser rescue analgesic requirement observed in the low BIS group could have been caused by the larger propofol dose as well. In order to be sure that the better postoperative pain relief was caused only because of a deeper anesthesia, authors should have used isoflurane to deepen anesthesia instead of propofol.
Journal of Anaesthesiology Clinical Pharmacology | April-June 2012 | Vol 28 | Issue 2
Pierre-Yves Lequeux, Emily Bui-Quôc, Gilbert Bejjani1 265
