Anesthesia & Clinical Research
Open Access

Abstract

Difficult Intubation in Patient with Short Thyromental Distance: Usefulness of Tongue Traction Maneuver

Cortese A, Pantaleo G, Gargiulo M and Amato M

Introduction: Short Thyromental Distance (TMD; <5 cm) has been correlated with difficult direct intubation in adult patients. Differences in patient characteristics may influence the incidence of difficult airway intubation, especially in patients with a reduced mandible dimension. We report a case affected by Goldenhar’s syndrome treated for mandibular hypoplasia with difficulties in intubation. Methods: A 25 years old caucasian woman was referred to the Unit of Maxillofacial Surgery of the University of Salerno, with bilateral Goldenhar’s syndrome, planned for a sandwich osteotomy as “chin-wing” mentoplasty following Triaca technique with the aid of the tongue traction maneuver in combination with fibroscopy at intubation time. Following Mallampati classification anesthesiologists, before surgery, classified the airways as easy or difficult according to specified criteria. Discussion: The anesthesiologist’s prediction changed from difficult grade 3 to difficult grade 4 at the time of operation, this because the patient had showed a severe reduction of the mandibular length with the tongue position of the tongue which overlapped the epiglottis making very difficult laryngeal glottis view at the intubation time. Efficacy of the “Tongue traction maneuver” in combination with a planned fibroscopy is reported. High risks of dispnea in short mandible patients at the extubation time after mandible surgery for tongue and pharyngeal swelling are also underlined. Conclusions: Anesthesiologists can derive useful information from facial appearance and facial skeleton, by panoramic X-rays of the jaws, X-ray cephalograms and CT scan analysis that enhances the prediction of a difficult airway intubation. Particularly mouth opening limitations and mandibular operations planning with post-operative tongue and pharyngeal swelling and consequent airway obstruction at the extubation time, have to be carefully evaluated. In craniofacial surgery importance of some maneuvers like “tongue traction” in short thyromental distance alone or in addition to fibroscopy for limited mouth opening cases and a “double step intubation” for narrow nasal airway’s are reported.