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  • 8/3/2019 3.Retrograde

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    Summary:

    Keywords:

    Temporomandibular joint ankylosis (TMJ) is always a challenge to intubate. We successfully carried out endotracheal

    intubation in a 12 yr oldpatient whowas postedfor corrective surgery using retrograde intubation technique.

    retrogradeintubation, TMJ ankylosis, guidewire,difficult intubation

    Introduction

    Casereport:

    Authors& Correspondence

    :

    The establishment of an airway by orotracheal

    intubation in TMJAnkylosis is always a challenge to the

    anaesthesiologist. A number of techniques are followed

    for intubation like blind nasal intubation, retrograde

    intubation using a guide wire, fibreoptic laryngoscopy

    and finally tracheostomy. We followed retrograde

    intubation using flexible J tippedguidewire.

    A 12 yr, ASA grade I, male child, weighing 22 kg was

    our patient. Parents gave history of inability to open his

    mouth since birth. He was diagnosed as a case of B/L

    T MJ a n ky l os i s a n d w as t o u n de rg o B / L

    osteoarthrotomy. His neck mobility was normal. We

    planned for retrograde intubation technique using

    flexible J-tipped guidewire.

    The procedure and the possibility of resorting to

    tracheostomy was explained in their native language

    and consent was taken from parents. IV line secured

    using 20G IV cannula in right arm. Monitors used werepulseoximeter, ECG,NIBPand capnography.

    Pre-op 45 min prior to the procedure i.m atropine

    0.6mg wasgiven. Xylometazoline nasal drops instilled.

    Topical 10% xylocaine sprayed into the mouth. Inj

    midazolam 0.5mg IV given. Inj propofol (25mg) IV

    given initially and then intermittently 10mg IV was

    given. B/L superior laryngeal nerves blocked using 1%

    lidocaine 2ml on each side was given. Airway reflexes

    were additionally blunted by instilling 4% lidocaine

    into trachea via 24G needle which was introduced into

    trachea through the cricothyroid puncture.Under strict asepsis, 18G Tuohy epidural needle was

    used to puncture the trachea around 2-3 cm below the

    cricothyroid membrane with the needle directing upwards.

    Prof.&Head*

    Asst.Prof.

    Assoc.Prof

    Prof.&Head(DepartmentofPlasticSurgery)

    PostGraduatestudent

    Departmentof Anaesthesiology,KLE

    University'sJ.N.MedicalCollege&KLESDr.

    PrabhakarKoreHospital,Belgaum

    * Dr.CSSanikop:09448863688

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    RetrogradeIntubationinTemperomandibularJointAnkylosisDr.C.S.Sanikop ;Dr.Manjunath.C.Patil ;DrRajesh.S.Mane ;Dr.RajeshPowar ,Dr.TaraNandan

    0 v 9 V s

    Through this the flexible J tipped guide wire was

    passed whichnegotiated the curved pathway afterthree

    attempts and came out of the nostril. The whole

    procedurewasvisualizedusing fluoroscope.

    The tuohy needle was then removed keeping the

    guide wire intact. No.6 COETT was passed through the

    guide wire. The guide wire was then removed and tube

    passed further down. IPPV was started manually and

    tube position confirmed by auscultating the chest and

    monitoring EtCO2. We gave vecuronium and propofol.

    Anaesthesia maintained with IPPV by O +N O+

    Halothane 0.5%- 1%. At the end of surgery mouthopening was two fingers. Residual neuromuscular

    block was reversed. Extubation was done when patient

    was awake, responding to oral commands and airway

    reflexes were present. The subsequent recovery was

    uneventful.

    In our patient conventional intubation of the trachea

    was impossible. In cases of difficult airway, there are a

    number of other options like awake intubation, blind

    nasal intubation, intubation using a fibreoptic

    laryngoscope, using LMA, oesophageal trachealCombi-tube, tracheal jet ventilation, the use of McCoy

    laryngoscope, the use of light wand, retrograde

    intubation and tracheostomy.

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    Discussion:

    Fig1:TMJankylosis

    inthepatient

    Fig2:showing18GTuohyneedle

    puncturingthetrachea

    Fig3.fluoroscopicimageshowingthe'J'tippedguidewirenegotiatingthenasopharynx

    (theimagehasbeenmodifiedtohighlighttheguidewire.).

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    In our pediatric patient we opted for retrograde

    intubation as awake intubation or blind nasal

    intubation would be difficult (pt may not co-operate).

    The term retrograde intubation refers to a technique in

    which a guide wire is passed into the trachea and then

    into the mouth or nose. A tracheal tube is then passed

    down over the guide until it enters the trachea. This

    technique was first described by Butler and Cirillo in1960.

    Blind nasal carries a risk of nasal bleeding and is not

    alwayssuccessful, LMAwas notpossible to insert in our

    case due to limitation of the mouth opening. Fibreoptic

    intubation requires considerable experience before it is

    used in difficult cases. Tracheostomy also carries many

    risks particularlyin theabsence of a tracheal tube.

    The retrograde method has been used successfully in

    many patients even in infants and the technique proved

    to be straightforward method of tracheal intubation in

    our patient. Although there are some complicationsmentioned in the literature like bleeding from the nose

    or from the site of cricothyrotomy, minimal

    subcutaneous emphysema, infections like pretracheal

    abscess, airway trauma,we have not encountered any

    complications in our case. Thus, even in an emergency

    scenario retrograde nasal intubation could be a suitable

    alternative.

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    References:

    1. Butler F S, Cirillo A A. Retrograde tracheal intubation. AnesthAnalg 1960; 39:333-338.

    2. Williamson R. The airway decides the anaesthetic approachbefore trachealintubation.Br.J. Anaesth1993;70: 601.

    3. Waters DJ. Guided blind endotracheal intubation: for patientswithdeformitiesof theupper airway. Anaesthesia 1963; 18:158-62.

    4. Van Stralen DW, Rogers M, Perkin RM, FeaS. Retrograde intubation

    trainingusinga mannequin. Am J Emerg Med1995;13:50-2.5. HarrisonW, BertrandM, AndewegS, Clark J. Retrograde intubation

    around an in situ Combitube: A difficult airway managementstrategy. Anesthesiology 2005; 102:1061-2.

    6. Gill M, Madden MJ, Green SM. Retrograde endotrachealintubation: An investigation of indications, complications, andpatientoutcomes. Am J Emerg Med2005; 23:123-6.