Department of Anaesthesiology, Queen Mary Hospital, Pokfulam, Hong Kong, Peoples Republic of China*Corresponding author
Accepted for publication: October 2, 2001
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Abstract |
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Br J Anaesth 2002; 88: 28891
Keywords: anaesthesia; equipment, tubes tracheal; intubation tracheal, submental; complications, haemoglobinopathy; complications, beta-thalassaemia major
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Introduction |
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Case report |
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General anaesthesia was induced by i.v. injection of fentanyl 100 µg and propofol 150 mg. Direct laryngoscopy (Cormack and Lehane grade 2) and oral tracheal intubation with a size 7.0-mm ID (internal diameter) RAETM tube (Mallinckrodt Medical, Ireland) was facilitated with injection of cisatracurium 8 mg after confirmation of easy mask ventilation. Anaesthesia was maintained by nitrous oxide in oxygen and isoflurane. A 22-G arterial cannula was inserted into the left radial artery for continuous arterial blood pressure monitoring and for ease of blood sampling. A 16-G i.v. cannula and a long central venous line (Cavafix certo 375, B. Braun Medical, Germany) were inserted into the left forearm for i.v. fluid administration and central venous pressure monitoring. Surgery commenced with a 1.5-cm incision in the left submental region. Blunt dissection, whilst identifying and preserving both submandibular and lingual nerves, was carried out until the floor of the mouth was reached. Following 3 min pre-oxygenation of the patients lungs with 100% oxygen, a 6.5-mm ID silicone reinforced endotracheal tube (Willy Rüsch, Kernen, Germany) was inserted through the submental incision into the oral cavity. After thorough suctioning and removal of the oral tracheal tube, the reinforced tube was substituted. The process involved some degree of manipulation using a pair of Magill forceps as the new angle towards the trachea was very acute. The tube was fixed by suturing onto the submental area (Fig. 2). Surgery then preceded with Le Fort I maxillary osteotomy. To optimize surgical conditions and reduce intra-operative bleeding, the patient was positioned 15 degrees in the reverse Trendelenberg position and the systolic arterial blood pressure was maintained in the 8090 mm Hg range. This was facilitated using aliquots of labetalol (total 15 mg).
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The estimated blood loss was 11.8 litres. The fluid repletion regimem consisted of 4 litres of crystalloid, 3 litres of colloid, 16 units of packed red cells, and 10 units each of fresh frozen plasma and platelets. Because of concern about haemostasis and ensuing blood loss, the mandibular osteostomy and intermaxillary fixation procedures were abandoned (the mandible was overgrown with bone marrow, and attempts at applying the intermaxillary fixation plate would have resulted in further brisk bleeding). As the intermaxillary fixation procedure was no longer necessary, the endotracheal tube was removed from the submental incision and substituted with a 6.5-mm ID tracheal tube through the oral route via direct laryngoscopy at the end of surgery. The submental incision site was then closed. Mechanical ventilation of the lungs in the intensive care unit (ICU) was continued postoperatively because of the blood loss and potential airway compromise from tissue swelling. I.v. dexamethasone was continued postoperatively to reduce facial and laryngeal swelling. Her postoperative stay in the ICU was uneventful. She was weaned from ventilatory support and her trachea extubated 2 days after the procedure. The patient was discharged from the hospital on her tenth postoperative day.
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Discussion |
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We have described a unique case of a patient with severe facial bony deformities secondary to beta-thalassaemia major requiring surgery in an elective setting mainly for cosmetic reasons. Insertion of an endotracheal tube via the nasal passage was deemed impossible, as the maxilla was so overgrown, obstructing the nasal passages. As the planned procedure involved an intermaxillary fixation, the oral route for tracheal intubation was not feasible. A tracheostomy was considered to be an aesthetically inferior option by the patient and surgeon compared with using the submental route.
Two techniques for endotracheal tube placement via the submental route have been described previously. The first involved a plain oral endotracheal tube inserted after induction of general anaesthesia. A submental incision was then made and blunt dissection carried out as close to the mandible as possible until reaching the floor of the mouth was reduced. A pair of artery forceps was then passed into the channel created and the air injection port of the endotracheal tube grasped. The endotracheal tube connector was temporarily disconnected so that the body of the tube could be pulled through the floor of the mouth by the artery forceps and out through the submental opening.4 The connector was then reattached to the rest of the breathing circuit and ventilation continued. The second technique was described in 1996 by Green and Moore5 utilizing two separate tubes.6 After general anaesthesia and placement of an oral endotracheal tube, a second endotracheal was introduced through a submental incision and subsequently substituted into the larynx. We chose the latter technique for two reasons. The first reason was to minimize the apnoea time while passing the endotracheal tube through the submental passage, removing and reconnecting the plastic connector. The second reason was that the silicone-reinforced tube that we used in this case has a big air injection port attached to a three-way stopcock. This is relatively large and the incision would have to have been much larger to facilitate the passage of the entire tube. However, one drawback of using this technique that has not been emphasized previously is the possibility of cuff damage. Because of the acute angle that one has to manoeuvre the tube intra-orally for tube exchange, a pair of Magill forceps has to be used for manipulation. Repeated contact between the forceps and the cuff of the tube may increase the risk of cuff damage.
Some of the anaesthetic problems associated with the thalassaemia-major syndrome have been reported previously.7 8 Although genetic counselling has become widely available in the developed world, the authors still encounter an increasing number of patients presenting with severe forms of haemoglobinopathy, mainly from immigrant families from mainland China. Whilst modern treatments911 have prolonged survival in these patients, a proportion now present for corrective surgery of facial deformities.
The massive blood loss in this case arose because of the nature of the procedure, rather than pre-existing coagulopathy. The operation involved an osteotomy impinging on overgrown bone marrow, and in retrospect, we should have anticipated the propensity for severe bleeding. It could be argued that elective cosmetic surgery may not have been prudent in this patient. However, as the demand for surgery from the patient was so overwhelming, and considering the psychosocial impact of her facial deformities, we agreed to proceed after discussing all the risks with the patient.
In conclusion, the submental method is a novel, but under utilized, technique for tracheal intubation and has only previously been described in patients with craniofacial trauma. We have described successful use in a patient with severe facial deformities, as a result of underlying thalassaemia major. We conclude that this technique is a useful option, and should not only be limited to trauma patients, but extended to a wide spectrum of patients and may avoid some of the problems inherent with a tracheostomy. Patients with beta-thalassaemia major can present with minimal symptoms but can have major intra-operative problems, especially if the operation involves correction to the bony structure. It may be reasonable to consider the use of intra-operative blood salvage techniques or means to rapidly replete intra-vascular volume.
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References |
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