Tracheal intubation with nasal speculum in situ.

Sir,

The fundamental responsibility of an anesthesiologist is to ensure uninterrupted ventilation and oxygenation with a patent airway.[1] Incidence of difficult mask ventilation varies from 0.15% to 5%.[2] Here, we share our experience with an unusual scenario of impossible mask ventilation and an impending difficult intubation. A 45-year-old woman weighing 84 kg (body mass index (BMI): 28.7 kg/m2) was admitted to a private hospital with complaints of headache and blurred vision for 4 months. She was a known case of hypertension on amlodipine 5 mg for the previous 5 years, and diabetes mellitus on insulin since 1 year. A magnetic resonance image of brain showed dumbbell-shaped mass lesion arising from sella and extending into the suprasellar cistern and third ventricle, causing compression of optic tract and chiasma. She was diagnosed as a case of pituitary macroadenoma and transnasal transsphenoidal surgery was planned under general anesthesia. There was profuse nasal bleeding during the surgical procedure, after insertion of nasal speculum. Hence, the attending neurosurgeon abandoned the procedure. The speculum was left in situ along with additional nasal packing [Figure 1a] to prevent further bleeding, and trachea was extubated after reversal of residual neuromuscular blockade. Other details of the anesthetic course were unavailable. The patient was later referred to our hospital from a distance of 300 km. Investigations revealed a drop in hemoglobin concentration from initial 12.4 to 9.6 gm/dL. Rest of the investigations was normal. Digital subtraction angiography carried out under monitored anesthesia care showed no active bleeding from the surgical site and the patient was planned for excision of the tumor and removal of speculum. Intramuscular glycopyrrolate 0.2 mg was premedicated 45 min before induction of anesthesia. In the operating room, the patient was assessed to be dehydrated, anxious, and irritable with a heart rate and blood pressure of 98 beats/min and 156/84 mmHg, respectively. She had anticipated difficult mask ventilation owing to the presence of nasal speculum along with BMI > 26 kg/m2 and an edentulous airway.[2] Moreover, there was likelihood of obstruction to the laryngoscope blade during direct laryngoscopy. Hence, the patient was counseled for awake fiberoptic intubation and fentanyl 25 mg was given intravenously. The airway was anesthetized with bilateral superior laryngeal nerve block; transtracheal block with lignocaine 2%. Later, three puffs of lignocaine 10% were sprayed at the postpharyngeal wall. Fiberoptic bronchoscopy was performed and trachea was intubated with 7.0 cuffed endotracheal tube [Figure 1b]. After confirming tube position, the patient was anesthetized with intravenous propofol and fentanyl and was paralyzed with rocuronium. Anesthesia was maintained with O2, N2O, sevoflurane, and rocuronium. Blood loss, occurred mainly during speculum readjustment and nasal pack removal, was 800 mL, which was adequately replaced with crystalloids and blood. The possible reason for nasal bleeding was incorrect selection of nostril with wrong plane of advancement by the neurosurgeon, during first surgery. At the end of the procedure, neuromuscular blockade was reversed and trachea extubated [Figure 1c] when the patient became fully awake. In this case, we had two options to secure the airway: (a) awake fiberoptic intubation or (b) securing airway with a laryngeal mask airway after intravenous induction with anesthesia. The former was chosen owing to the risk of “losing the airway” once anesthesia was induced.[1] Although fiberoptic bronchoscopy helped us to secure the airway, a difficult airway cart was kept ready to prevent any untoward event. Fiberoptic intubation is the technique of choice in managing difficult airways.[3] This report re-emphasizes its importance as the “first choice tool” in critical situations where mask ventilation might be difficult.

Figure 1

(a) Nasal speculum (in situ) placed in left nostril, (b) intubated patient, and (c) postoperative patient