A 31year-old female presented with hard palate tumour occupying whole of the oral cavity with protruding mass outside teeth. She presented with a rapidly progressing proliferative mass of 10 months duration. The patient was on liquid diet for last 7 months as she could not chew due to the tumour. The patient was scheduled for resection of the tumour under general anaesthesia.On airway examination, the mouth was wide open with the mass protruding out between the upper and lower jaws [Figure 1] with lips free from the mass. Tongue could be protruded out beneath the mass. The upper jaw teeth were not visualised and lower jaw incisors and canines were loose. Hard palate could not be visualised due to the mass. Neck extension was within normal limit. CT scan showed an ill-defined heterogeneously enhancing mass lesion in hard palate extending posteriorly to soft palate and anteroinferiorly, abutting the teeth of upper and lower jaw without underlying bone erosion.
Figure 1
Hard palate mass protruding through the oral cavity
Hard palate mass protruding through the oral cavityAn awake, right nasotracheal intubation was planned. The patient was premedicated with Glycopyrolate 0.2 mg and Fentanyl 2 μg/kg intramuscularly half hour before the procedure. Emergency tracheostomy was kept ready. Oral and nasal cavity was sprayed with Lignocaine 10%. The patient was continuously explained about what was being done and full co-operation was achieved. A 7 mm cuffed PVC endotracheal tube was lubricated with lignocaine jelly and deformed for a few minutes to exaggerate the curvature. The EtCO2 cable was attached to the endotracheal tube and the tube was then introduced through the right nostril. As soon as glottis was reached as confirmed by EtCO2, the tube was introduced blindly, but after three failed attempts, one assistant lifted the tumour outside and a MacIntosh laryngoscopy blade was introduced through the right molar approach. As soon as the glotic orifice was visualised, Maggil's forcep was negotiated through the created molar space and the tube was guided toward the glottis. As soon as the tube entered the glottis, the patient was induced with Inj. Propofol followed by Vecuronium bromide. Surgery completed successfully and the patient extubated at the end of the procedure with uneventful recovery.
DISCUSSION
Patients presenting with intraoral swelling really pose a difficult laryngoscopy situation, as they physically occupy the oral cavity making glottic visualisation and endotracheal intubation difficult.[1] Various techniques are available to secure the airway in such situation, like the fibreoptic bronchoscopy (FOB). FOB intubation under local anaesthesia is the technique of choice for the management of the anticipated difficult intubation and mask ventilation.[23] The FOB intubation is best option for elective procedures, but has been considered difficult in maxillofacial traumapatients with intraoral bleed. One of a most commonly practiced technique in such situation is the molar approach of intubation, where Macintosh laryngoscopy blade is introduced from right side of mouth and advanced below the tongue up to the molar space pushing the tongue medially and directing tip of the blade postero-medially under the base of the tongue until the epiglottis is seen. The endotracheal tube is introduced and advanced from the corner of the mouth behind the molar space through the glottis opening under vision.[45] This approach reduces the distance from the teeth to the glottis area reducing the physical obstruction. But this is sometimes difficult with large intraoral masses where the molar space is also compromised unless the tumour is manipulated from outside as in our case. So, in situation where molar approach is not adequate, a technique called modified molar approach with pulling of the tumour externally can increase the molar space to negotiate the laryngoscope.
CONCLUSION
In cases of anticipated difficult intubation with intraoral tumours where molar approach is not adequate, a modified molar approach with tumour manipulation from outside can produce better glottic visualisation and is a better advocated technique.
Figure 1