Using stylet in airtraq optical laryngoscope for armored tube intubation: A new experience.

Sir,

A 70-year-old man with complaints of numbness in all the four limbs and difficulty in walking since eight months was admitted to the neurosurgical unit. Magnetic resonance imaging (MRI) scan revealed posterolateral disc protrusion at C3/C4 intervertebral level with compression on bilateral nerve roots with degenerative changes at all levels. A diagnosis of prolapsed intervertebral disc (PIVD) with compressive myelopathy with cervical ankylosis was made. Airway assessment revealed limited head extension and Mallampatti Class III.

The patient was scheduled for cervical decompression through posterior approach. Patient refused awake fiberoptic intubation. Conventional laryngoscopy was not advocated because it involves extensive neck movement. We planned for tracheal intubation with silicone wired armored endotracheal tube (ETT) 7.5 mm ID, using Airtraq as an intubating aid to minimize neck movement. The Airtraq laryngoscope is a newly introduced airway device to facilitate tracheal intubation in patients with both normal and difficult airway anatomy. The blade of Airtraq consists of two channels with one channel acting as the conduit for passing ETT (standard PVC) while the other channel consists of an optical system.[1]

After standard premedication, induction of anesthesia was done with propofol 2 mg/kg intravenous (IV) and neuromuscular relaxation was achieved with succinylcholine 1.5 mg/kg IV. It is difficult to guide the tube correctly through the channel of the Airtraq as a wire-reinforced ETT is flexible. We devised a unique way of inserting the armored ETT. A rigid stylet was introduced into the ETT giving it a preformed curved shape and rigidity [Figure 1]. The tube along with the stylet was then inserted in the conduit meant for the ETT in the Airtraq in the midline centralizing the vocal cord of the patient. The Airtraq and the stylet were then removed after confirmation of the ETT placement.

Figure 1

Armored tube with stylet in Airtraq

While having an attached channel for ETT in an Airtraq simplifies the procedure, it limits direct manipulation of the tube.[2] We used an armored tube as the surgery was to be performed in prone position. Manipulating and guiding an armored tube through the fixed channel of Airtraq would be nearly impossible without using a stylet due to the highly flexible nature of the tube. Xue et al., have used stylets in Airtraq for intubation with a reinforced tube[3] but they did not mention the type of patients they selected for their study.

We believe that the Airtraq laryngoscope can be used as an intubation aid for properly placing an armored ETT in patients who have a fixed neck deformity, for surgery of the cervical spine and other similar surgeries.