Muhammad Asghar Khan, Muhammad Shafaq, Tahir Manzoor.
Management of difficult airway by Retrograde Tracheal Intubation.
J Coll Physicians Surg Pak Jan ;13(5):284-6.

A case of difficult intubation is presented in a patient of adenoid cystic carcinoma with a large right-sided facial defect. She was managed with radiotherapy and a myocutaneous flap reconstruction was done with retrograde tracheal intubation.

Case Report: A 65 years old lean married woman, with no history of smoking and drug abuse presented with a large anatomical defect (8x5 cm) on the lower aspect of right side of her face with tongue visible through it. Her right half of the mandible was missing with collapse of nasal bridge. A biopsy of the lesion was taken which revealed adenoid cystic carcinoma. She underwent radiotherapy and later myocutaneous flap reconstruction of the defect was done. She had difficulty in mouth opening before operation and was placed in Mallampatti grade 4. Keeping in view the anticipated difficulty in translaryngeal intubation, the possibility of airway access by elective tracheotomy was discussed with the surgeon who requested to adopt an alternative technique as tracheotomy could pose hindrance in the surgical procedure. The technique of awake retrograde intubation was planned. ANESTHETIC MANAGEMENT: The patient was placed in supine position with the neck extended in a head ring. The patient was monitored with ECG, DINAMAP and pulse oximetry. An intravenous access was established and the patient was sedated with 75 micrograms of fentanyl and 5 mg of midazolam. Cricothyroid membrance was identified and the anterior aspect of the neck was aseptically prepared and draped. The cricothyroid area was infiltrated with 1% lignocaine using a 25-gauge needle. A 16-gauge intravenous cannula was introduced through the cricothyroid membrance. As the location of the trachea was confirmed by aspiration of air through the cannula, the stillete was removed and 5 ml of lignocaine 2% sprayed in the trachea through the cannula. A guide wire was passed through the cannula towards the oropharynx. The wire was felt in the mouth by a gloved finger placed through the right cheek defect. The wire was guided with the same finger and directed upwards to come out of the patient`s mouth. A 7.5 mm cuffed endotracheal tube (ETT) was threaded over the guide wire and successfully placed in the trachea. Position of ETT was confirmed and secured. The cannula as well as the guide wire was withdrawn and the patient was routinely anesthetized. After the surgery was over the effect of relaxant was reversed and the patient was shifted to main intensive treatment center & ETT was removed after 24 hours and the patient was shifted to ward, where she received antibiotics and analgesics.

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