Use of Proseal, as an alternative to conventional facemask, to facilitate ventilation in anticipated difficult mask ventilation.

Sir,

A 50 kg, 55-year-old man with a rapidly growing 20 cm × 20 cm × 15 cm mobile facial soft tissue tumor over the right cheek (extending superiorly to the infraorbital region, anteriorly till angle of mouth, laterally three finger breadth from tragus and inferiorly till lower border of mandible) was scheduled for growth excision [Figure 1]. Patient's mouth opening was ~5 cm, tempero-mandibular distance 7 cm and the airway was Mallampati grade 2. Contrast enhanced computed tomography neck revealed a tumor localized to right cheek externally without any extension and intact mucosa. Difficult mask ventilation was anticipated as the large tumor was distorting the angle of mouth potentially making an air tight seal difficult.

Figure 1

Picture showing soft tissue mass distorting the angle of mouth making air tight seal with face mask difficult.

Electrokardiogram, noninvasive blood pressure, pulse oximetry and capnometry monitoring were initiated. Xylometazoline 2-4 drops were administered in the left nostril of the patient to decongest the nasal mucosa. Fentanyl 100 mcg, midazolam 1 mg, rantidine 50 mg and metoclopramide 10 mg intravenous (IV) were administered. Patient was preoxygenated with 100% O 2and after 5 minutes anesthesia was induced slowly with titrated IV dose of propofol (to total of 100 mg) maintaining spontaneous ventilation. Proseal #3 was inserted after adequacy of ventilation was confirmed [Figure 2]. Randall Baker Soucek mask #2 with Bain circuit attached for intraoral placement and a conventional facemask #4 with adequate gauze pieces were kept as standby. Vecuronium 5 mg IV was given for neuromuscular blockade. Anesthesia was maintained with sevoflurane 3-4% in 100% O2. Flexometallic tube 7 mm ID was introduced from left nostril and advanced till beyond posterior nares. Thereafter, Proseal was removed, laryngoscopy performed and trachea successfully intubated with the tube. Oxygen saturation remained constant to ≥98% during airway instrumentation. Anesthesia was maintained with standard technique. Rest of the perioperative period was uneventful.

Figure 2

Photo showing patient being ventilated by Proseal.

Mask ventilation is an essential and fundamental skill in airway management.[1] Anticipating difficult mask seal, Proseal was used for ventilation instead of a conventional facemask. Awake fiberoptic intubation could have been the method of securing airway but the equipment was malfunctioning. The difficult airway algorithm of American Society of Anesthesiologists recommends use of supraglottic devices in failed ventilation/intubation.[2]

Case reports document the utility of supraglottic devices in restoring the ability to ventilate patients who could neither be ventilated nor intubated immediately after induction of general anesthesia.[3-6] Proseal has been found useful in management of the difficult airway and for airway rescue.[5]