Anaesthesia, 2005, 60, pages 817–830 Correspondence ...................................................................................................................................................................................................................... 4 European Union. Medical Device Directive (MDD) 93 ⁄ 42 ⁄ EEC. 5 Scott DHT. British Standards Institute report. ACTA Newsletter 2003; 17:5. Use of the laryngeal tube after failed insertion of a laryngeal mask airway The Laryngeal Tube (VBM, Medizin- technik, Germany) has a potential role during anaesthesia and cardiopulmon- ary resuscitation [1, 2]. It consists of an airway tube with a small balloon cuff attached at the tip and a larger Figure 3 Distal part of the laryngeal tube (left) and the laryngeal mask airway (right). balloon cuff at the middle part of the tube. We report successful use of the 100 mg and maintained with a target- distal part of the mask had wedged in laryngeal tube in three patients in controlled infusion. After no motor the narrowed pharynx. The distal whom insertion of the laryngeal mask response to jaw thrusting had been segment of the laryngeal tube is not airway had failed. An 18-year-old fit confirmed, insertion of a laryngeal tapered, and the width of the tube is and healthy woman (165 cm, 52 kg) mask airway was attempted, but it narrower than that of the laryngeal was scheduled for left oophorectomy. was impossible to advance it beyond mask airway (Fig. 3), and thus the After epidural catheterisation, general the back of the throat. In contrast, laryngeal tube might have passed anaesthesia was induced with propofol insertion of a laryngeal tube was easy. through the narrowed space. We 100 mg and deepened with sevoflura- The operation (40 min) proceeded suggest that, when insertion of the ne. After no motor response to thrust- without complications. laryngeal mask airway is difficult or ing the jaw forward had been A 72-year-old man (157 cm, 74 kg) impossible due to a narrowed pha- confirmed [3], the mouth was opened was scheduled for right total hip ar- rynx, insertion of the laryngeal tube to insert a laryngeal mask airway. throplasty. Preoperatively, difficult tra- may be attempted, before considering Enlarged tonsils were found. Because cheal intubation was predicted, because tracheal intubation. there was a gap between the tonsils the view of the oropharynx was limited T. Asai (approximately 1.5 cm), we felt that it (Mallampati score 3), the thyromental S. Matsumoto might be possible to insert the laryn- distance was 5 cm, there was a mild K. Shingu geal mask, but failed to advance the difficulty in thrusting the jaw forward Kansai Medical University device beyond the tonsils despite using and extending the neck, and snoring Osaka, 570–8507, Japan the insertion technique described in during sleep. After epidural catheterisa- E-mail: [email protected] the manufacturer’s instruction manual. tion, anaesthesia was induced with T. Noguchi Insertion of a flexible laryngeal mask propofol 150 mg. Insertion of a laryn- Kyushu Rosai Hospital (which should be easier to insert in geal mask failed twice. In contrast, a Fukuoka, 800–0296, Japan patients with enlarged tonsils) also laryngeal tube was easily inserted and K. Koga failed. Before tracheal intubation, we was used during anaesthesia of 140 min, University of Occupational and tried a laryngeal tube, which was without complications. Environmental Health easily inserted. The lungs were venti- The exact reason for successful Fukuoka, 807–8555, Japan lated through the laryngeal tube with- insertion of the laryngeal tube after out complications during the 80 min failed insertion of the laryngeal mask operation. airway in these cases is not known, Conflict of interest A 46-year-old woman (159 cm, but the success and failure might have None of the authors has received any 55 kg), with a history of Basedow’s been related to a difference in the financial support from the manufactur- disease at 20 years and tonsillectomy width of these two devices. The ers of the laryngeal mask airway or the at 34 years, was scheduled for left pharyngeal space was narrowed by laryngeal tube. oophorectomy. Preoperative examina- swollen tonsils in case 1, by a goitre tion indicated a goitre (with normal in case 2, and possibly by redundant References thyroid function) without deviation of tissues in the pharynx (which pro- 1 Asai T, Murao K, Shingu K. Efficacy of the trachea or difficulty in breathing. duced the snoring) in case 3. Insertion the laryngeal tube during intermittent After epidural catheterisation, general of the laryngeal mask airway might positive pressure ventilation. Anaesthesia anaesthesia was induced with propofol not have been possible because the 2000; 55: 1099–102. Ó 2005 Blackwell Publishing Ltd 825 Correspondence Anaesthesia, 2005, 60, pages 817–830 ...................................................................................................................................................................................................................... 2 Asai T, Moriyama S, Nishita Y, of the laryngeal tube), and identify solutions. British Journal of Anaesthesia Kawachi S. Use of the laryngeal tube the distal cuff of the laryngeal tube in 2004; 92: 870–81. during cardiopulmonary resuscitation the hypopharynx, and anterior to 3 Asai T. Difficulty in insertion of the by paramedical staff. Anaesthesia 2003; that, the glottis through a narrow gap laryngeal mask. In: Latto IP, Vaughan 58: 393–4. (< 1 cm) between the epiglottis and RS, eds. Difficulties in Tracheal Intuba- 3 Drage MP, Nunez J, Vaughan RS, arytenoids. The laryngeal inlet was tion, 2nd edn. London: W.B. Saunders, Asai T. Jaw thrusting as a clinical test tilted to the right, due possibly to the 1997: 197–214. to assess the adequate depth of anaes- radiotherapy. After 20 min and with 4 Asai T, Marfin AG, Thompson J, Popat thesia for insertion of the laryngeal considerable difficulty, the fibrescope MK, Shingu K. Ease of insertion of the mask. Anaesthesia 1996; 51: 1167–70. was advanced into the trachea while the laryngeal tube during manual-in-line lungs were kept ventilated through the neck stabilization. Anaesthesia 2004; 59: laryngeal tube. It was then relatively 1163–6. easy to advance the tracheal tube into 5 Matioc AA, Olson J. Use of the laryn- Use of the laryngeal tube for the trachea. The laryngeal tube was geal tube in two unexpected difficult difficult fibreoptic tracheal then removed. airway situations: lingual tonsillar hyper- intubation Fibreoptic intubation is useful in plasia and morbid obesity. Canadian patients with a difficult airway, but it Journal of Anaesthesia 2004; 51: 1018–21. I have previously reported that venti- can be difficult to locate the glottis, to 6 Asai T, Matsumoto S, Shingu K, lation can be controlled via the lar- advance a tracheal tube over the fibre- Noguchi T, Koga K. Use of the yngeal tube (VBM, Medizintechnik, scope, and to ventilate the lungs during laryngeal tube after failed insertion of a Sulz, Germany) during attempts at the procedure [2]. In the case reported, laryngeal mask airway. Anaesthesia 2005; fibreoptic nasotracheal intubation and the laryngeal tube provided a clear 60: 824–5. used this technique in a patient with airway and enabled delivery of oxygen multiple fractures of the jaw in whom and inhalational anaesthetics during the Loss of resistance syringes thrusting the jaw forward (during prolonged attempt at fibreoptic naso- mask ventilation) and tracheal intuba- tracheal intubation. It also facilitated I was interested to read about the tion using a laryngoscope might wor- location of the glottis through a fibre- problem with a false positive ‘loss of sen the damage to the jaw [1]. I now scope: the glottis should be anterior to resistance’ syringe and the reply [1]. report successful use of this technique the distal cuff of the laryngeal tube in Having performed epidural analgesia for in a patient in whom laryngoscopy, the hypopharynx. 42 years, I can state honestly that I have conventional fibreoptic intubation and Insertion of the laryngeal mask failed never found the need for a specific insertion of the laryngeal mask airway whereas insertion of the laryngeal tube syringe to find the epidural space. For had failed. was successful. Insertion of the laryngeal roughly the first 15 years of my career I A 71-year-old man with a history of mask, or of the laryngeal tube, may be used glass syringes, which would occa- partial resection of the tongue was difficult in some circumstances [3, 4]. sionally stick alarmingly. For the last scheduled for revision of the resection, However, there have been reports in 27 years I have used standard disposable due to recurrence of cancer. Because of which the laryngeal tube provided syringes (from a variety of manufac- radiotherapy, mouth opening was lim- adequate ventilation after failed insertion turers) without finding any reason to ited to 3 cm and extension of the neck of the laryngeal mask [5, 6]. Elucidating change. The standard modern dispo- was restricted. After induction of ana- the causes of difficult insertion of the sable syringes are quite sensitive enough esthesia and confirmation of adeq- laryngeal mask and of laryngeal tube to pick up subtle changes in resistance as uate mask ventilation, vecuronium was would establish the role of these devices the needle attached to a syringe of saline given. Attempted nasotracheal intuba- in patients with difficult airways. with constant pressure on the plunger, tion using a Macintosh laryngoscope, of course, passes through the ligaments. T. Asai followed by use of a fibrescope, failed Regional anaesthesia will be even more Kansai Medical University because a large epiglottis reclining to widely practised if the techniques are Moriguchi City, Osaka, 570–8507, posterior pharyngeal wall prevented kept simple and unnecessary special Japan visualisation of the glottis. Insertion of pieces of equipment are discouraged. a size 4 followed by a size 3 laryngeal E-mail: [email protected] mask airway also failed, due mainly to A. P. Rubin inability to insert an index finger into References Chelsea and Westminster Hospital the oropharynx to drive the mask into 1 Asai T, Shingu K.