Dilemma of gum bleeding after flexible laryngeal mask airway insertion in children.

Sir,

We encountered gum bleeding in two children after insertion of flexible laryngeal mask airway with finger technique under general anaesthesia. In the first child, gum bleed from upper right central incisor bed was noticed. Lighted blade of Macintosh laryngoscope was inserted over the dorsal surface of LMA cuff and tooth was removed with the help of Magill forceps. In the second child, gum bleed from lower second right incisor bed was noticed. LMA was removed and with direct laryngoscopy, tooth (right upper last molar fossa) was removed with Magill forceps. Presence of loose deciduous tooth was not documented in the pre-anesthetic checkup in both the cases and the insertion of FLMA was very smooth.

Consequences of tooth dislodgment can be serious and may sometime need bronchoscopy for removal of the tooth. A dental history and oral examination are important part of PAC.[1] Clear documentation of the patient's preoperative dental condition and notifying the patient about potential dental damage may diminish costs for postoperative dental treatment.[2] Though examination and confirmation of loose teeth is difficult in mentally retarded children.

Incidents of minor tongue – lip - teeth trauma have been reported more during insertion and removal of ProSeal and intubating LMAs as compared to classic LMA.[3] But there is no report of dental injury with flexible LMA insertion.

Chances of dislodgment may be more with upper incisors as LMA cuff touches the upper incisors during insertion especially with limited mouth opening. In case of loose upper incisor, LMA provides a barrier and tooth may be impacted on dorsal surface of the cuff. In contrast if lower incisor is broken or detached during insertion of LMA it may go forward (trachea and bronchus) along with the LMA as happened in second case.

This report highlights the problem and panic due to dislodgment of unnoticed and undocumented loose deciduous tooth. Gum bleeding after insertion of any airway device should not be taken lightly. Newnam suggested examination of the dental arches with Gloved finger after induction of anesthesia, prior to insertion of LMA for detection of sharp projections of teeth.[4] This technique can also be utilized for detection of loose teeth.