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Table of Contents
LETTER TO EDITOR
Year : 2015  |  Volume : 31  |  Issue : 4  |  Page : 568

High arch palate: A bane for ProSeal laryngeal mask airway but a boon for I-gel


Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication5-Nov-2015

Correspondence Address:
Amarjyoti Hazarika
Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.169098

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How to cite this article:
Bala R, Hazarika A, Pandia MP, Kumar N. High arch palate: A bane for ProSeal laryngeal mask airway but a boon for I-gel . J Anaesthesiol Clin Pharmacol 2015;31:568

How to cite this URL:
Bala R, Hazarika A, Pandia MP, Kumar N. High arch palate: A bane for ProSeal laryngeal mask airway but a boon for I-gel . J Anaesthesiol Clin Pharmacol [serial online] 2015 [cited 2020 Feb 21];31:568. Available from: http://www.joacp.org/text.asp?2015/31/4/568/169098

Sir,

High-arched palate, a common occurrence of various syndromes, is a known cause of difficult laryngoscopy. [1] It may also lead to difficult laryngeal mask airway (LMA) insertion. We, hereby, report a case of failed ProSeal (PLMA) insertion in a 12-year-old female patient with brachial plexus injury where i-gel was successfully inserted at the first attempt. Her airway examination showed Mallampati grade I, adequate mouth opening and normal neck movements. Mask ventilation was adequate. After adequate depth of anesthesia, a well-lubricated PLMA size 3 using introducer tool technique was inserted. A resistance was felt in the oral cavity which could not be negotiated. Then, the digital technique was tried but failed. We opted for size 2΍ presuming that size 3 is too big. We were able to place it with slight resistance but there was significant air leak. Finally, we decided to try i-gel of size 3 which was placed successfully at first attempt without encountering any resistance. Air leak test was done and position of the device was confirmed using fiberoptic bronchoscope.

Management of brachial plexus injuries is unique as neuromuscular blockade should be avoided to facilitate intraoperative peripheral nerve monitoring. The surgeries are usually long duration. Supraglottic airway devices with esophageal vent such as ProSeal LMA, i-gel, LMA-supreme are best suited as patient's tolerance and acceptability is good and chances of aspiration are minimal. [2]

We speculated various causes for failure of PLMA insertion in our case. First, the device must have been impinging on the back of palate hence could not be slipped into hypopharynx. Second, there could have been narrowing of space at the back of oropharynx. Moreover, acute angulation might have prevented its rotation. i-gel being made up of soft elastomer, nonrigid, therefore, got moulded according to airway anatomy without facing any resistance. There are concerns that inflatable cuff of PLMA may impede its proper placement. Alternative techniques have also been described like introducer tool technique, digital and gum elastic bougie technique. [3] I-gel is found to have easier and quicker insertion than PLMA. [4] There is no perfect device and imperfections are related to various anatomical and pathological factors. Our case elucidates that although these devices are similar, they are not same and failure of one does not imply to all. One should have familiarity and expertise in all of them in face of difficult airway scenario.

 
  References Top

1.
Kaymak C, Gulhan Y, Ozcan AO, Baltaci B, Unal N, Safak MA, et al. Anaesthetic approach in a case of Goldenhar's syndrome. Eur J Anaesthesiol 2002;19:836-8.  Back to cited text no. 1
[PUBMED]    
2.
Ramesh S, Jayanthi R. Supraglottic airway devices in children. Indian J Anaesth 2011;55:476-82.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Brimacombe J, Keller C, Judd DV. Gum elastic bougie-guided insertion of the ProSeal laryngeal mask airway is superior to the digital and introducer tool techniques. Anesthesiology 2004;100:25-9.  Back to cited text no. 3
    
4.
Chauhan G, Nayar P, Seth A, Gupta K, Panwar M, Agrawal N. Comparison of clinical performance of the I-gel with LMA ProSeal. J Anaesthesiol Clin Pharmacol 2013;29:56-60.  Back to cited text no. 4
[PUBMED]  Medknow Journal  




 

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