A newborn with pedunculated teratoma of oral cavity: Possible role of modified nasopharyngeal airway in yet another situation of impossible mask ventilation.

Sir,

We read with interest the well-written letter to the editor, “Anesthestic management of a newborn for pedunculated teratoma of oral cavity” by Mishra et al.[1] It appears that the authors’ remained fortunate enough to intubate the trachea of the newborn with pedunculated teratoma of oral cavity. However, a closer look reveals noncompliance to the difficult airway guidelines and thereby, the authors could have landed in the “can’t ventilate and can’t intubate” scenario.

First, pedunculated teratoma of oral cavity has created a situation of difficult or almost impossible mask ventilation. As adequate seal with facemask seemed to be impossible the proper preoxygenation is rather difficult to expect. Second, performing a check laryngoscopy (DL scopy) in an awake patient without proper preparation of the airway with local anesthetics could have resulted in laryngospasm or bronchospam, a risky situation that could not have been managed immediately by the alternative airway techniques (cricothyroidectomy and jet ventilation/traceostomy) arranged as standby procedures. Third, induction of anesthesia even when the Cormack Lehan grade 4 view of glottis was revealed on DL scopy was a dreaded step, especially when the mask ventilation was almost impossible.

We suggest that after preparation of the nasal passage with topical lignocaine, an appropriate size modified nasopharyngeal airway (MNPA) or warmed endotracheal tube could have been inserted. Adequate lubrication with lignocaine jelly could facilitate easy and safe placement of MNPA in an awake patient.[23] Such an airway could be used as a primary tool for induction of inhalational anesthesia and also as a “dedicated airway” in patients with impossible mask ventilation.[3] Further, the technique of delivering positive pressure ventilation via MNPA with mouth and opposite nostrils closed using one hand has been described;[2] it could be further modified according to the need of the case.[3] The DL scopy could be considered following inhalational induction through the MNPA. The MNPA could also be used to facilitate fiberoptic-guided nasal as well as oral tracheal intubation in small children with difficult airway.[4] In similar fashion, the binasopharyngeal airway system could be used to eliminate the need for the facemask early during inductioin.[5]

Although the MNPA or the binasopharyngeal airway system has yet not been included in the current difficult airway algorithm, these could prove to be useful while managing the problems of expected or unexpected difficult mask ventilation. We believe that familiarity with these devices is highly desirable and should be considered while managing expected difficult or impossible mask ventilation as encountered in the present pediatric patient with pedunculated teratoma of oral cavity.