Universally, anesthesiologists are expected to be knowledgeable, astutely responding to clinical challenges while maintaining a prolonged vigilance for administration of safe anesthesia and critical care. A fatigued anesthesiologist is the consequence of cumulative acuity, manifesting as decreased motor and cognitive powers. This results in impaired judgement, late and inadequate responses to clinical changes, poor communication and inadequate record keeping. With rising expectations and increased medico-legal claims, anesthesiologists work round the clock to provide efficient and timely services, but are the "sleep provider" in a sleep debt them self? Is it the right time to promptly address these issues so that we prevent silent perpetuation of problems pertinent to anesthesiologist's health and the profession. The implications of sleep debt on patient safety are profound and preventive strategies are quintessential. Anesthesiology governing bodies must ensure requisite laws to prevent the adverse outcomes of sleep debt before patient care is compromised.

Background: The α2-adrenoreceptor agonist, dexmedetomidine, provides excellent sedation with minimal cardiovascular instability or respiratory depression and may be a useful adjunct to facilitate smooth tracheal extubation. Materials and Methods: Fifty American Society of Anesthesiologists grade I-II patients, aged 20-45 years, scheduled for elective general surgical, urological and gynecological surgeries were studied after randomization into two groups. Group A and B, received an intravenous infusion of dexmedetomidine 0.75 mcg/kg or placebo respectively, over 15 minutes before anticipated time of end of surgery, in a double blind manner. Anesthesia techniques were standardized. Heart rate, systolic, diastolic, mean arterial pressures were recorded while starting injection, at 1, 3, 5, 10, 15 minutes after starting injection, during extubation, at 1, 3, 5 minutes after extubation, and thereafter every 5 minutes for 30 minutes. Quality of extubation was evaluated on a 5 point scale and postoperative sedation on a 6 point scale. Any event of laryngospasm, bronchospasm, desaturation, respiratory depression, vomiting, hypotension, undue sedation was noted. Results: Heart rate, systolic, diastolic, mean arterial pressures were significantly higher in group B ( P < 0.05). Extubation quality score of majority of patients was 2 in group A and 3 in group B. Sedation score of most patients was 3 in group A and 2 in group B. Bradycardia and hypotension incidences were higher in group A. One patient in group A, two patients in group B had vomiting. No patient had any other side effects. Conclusion: Dexmedetomidine 0.75 mcg/kg administered 15 minutes before extubation, stabilizes hemodynamics and facilitates smooth extubation.

Background: A desirable combination of smooth extubation and an awake patient after neurosurgical procedures is difficult to achieve in patients with skull pins. Lignocaine instilled into endotracheal tube has been reported to suppress cough by a local mucosal anesthetizing effect. We aimed to evaluate if this effect will last till extubation, if given before pin removal. Materials and Methods: A total of 114 patients undergoing elective craniotomy were divided into three groups and were given 1 mg/kg of intravenous (IV), 2% lignocaine (Group 1), placebo (Group 2) and 1 mg/kg of 2% lignocaine sprayed down the endotracheal tube (Group 3) before skull pin removal. The effectiveness of each to blunt extubation response was compared. Plasma levels of lignocaine were measured 10 min after administration of the study drug and at extubation. Sedation scores were noted, immediately after extubation and 10 min later. Results: Two percent of lignocaine instilled through endotracheal route was not superior to the IV route or placebo in attenuating cough or hemodynamic response at extubation when given 20-30 min before extubation. The plasma levels of lignocaine (0.8 μg/ml) were not high enough even at the end of 10 min to have a suppressive effect on cough if given IV or intratracheally (IT). Lignocaine did not delay awakening in these groups. Conclusion: IT lignocaine in the dose of 1 mg/kg does not prevent cough at extubation if given 20-30 min before extubation. If the action is by a local mucosal anesthetizing effect, it does not last for 20-30 min to cover the period from pin removal to extubation.

Background: Analgesia and sedation are usually required for the comfort of the patient and surgeon during tympanoplasty surgery done under local anesthesia. In this study, satisfaction scores and effectiveness of sedation and analgesia with dexmedetomidine were compared with a combination of midazolam-fentanyl. Materials and Methods: Ninety patients undergoing tympanoplasty under local anesthesia randomly received either IV dexmedetomidine 1 μg kg ^-1 over 10 min followed by 0.2 μg kg ^-1 h ^-1 infusion (Group D) or IV midazolam 0.06 mg kg ^-1 plus IV fentanyl 1 μg kg ^-1 over 10 min (Group MF) followed by normal saline infusion at 0.2 ml kg ^-1 h ^-1 . Sedation was titrated to Ramsay sedation score (RSS) of three. Vital parameters, rescue analgesics (fentanyl 1 μg kg ^-1 ) and sedatives (midazolam 0.01 mg kg ^-1 ), patient and surgeon satisfaction scores were recorded. Results: Patient and surgeon satisfaction score was better in Group D than Group MF (median interquartile range (IQR) 9 (8-10) vs. 8 (6.5-9.5) and 9 (8.5-9.5) vs. 8 (6.75-9.25), P = 0.0001 for both). Intraoperative heart rate and mean arterial pressure in Group D were lower than the baseline values and the corresponding values in Group MF ( P < 0.05). Percentage of patients requiring rescue fentanyl was higher in Group MF than Group D (40% vs. 11.1%, P = 0.01). One patient in Group D while four in Group MF (8.8%) required rescue sedation with midazolam ( P > 0.17). Seven patients in Group D had dry mouth vs. none in Group MF ( P = 0.006).One patient in Group D had bradycardia with hypotension which was effectively treated. Conclusion: Dexmedetomidine is comparable to midazolam-fentanyl for sedation and analgesia in tympanoplasty with better surgeon and patient satisfaction. Hemodynamics need to be closely monitored.

Background: Morbidly obese patients with obstructive sleep apnea are extremely sensitive to sedative premedication. Intranasal dexmedetomidine is painless and quick acting. Intranasal dexmedetomidine can be used for premedication as it produces adequate sedation and also obtund hemodynamic response to laryngoscopy and tracheal intubation. Materials and Methods: Forty morbidly obese patients with BMI > 35 were chosen and divided into two groups. Group DEX received intranasal dexmedetomidine 1 mcg/kg (ideal body weight) while other group (AZ) received oral alprazolam 0.5 mg. Sedation scale, heart rate and the mean arterial pressure was assessed in both the groups at 0 hour, 45 minutes, during laryngoscopy and tracheal intubation. Results: The demographic profile, baseline heart rate, means arterial pressure, oxygen saturation and sedation scale was comparable between the two groups. The sedation scores, after 45 min, were statistically significant between the two groups i.e., 2.40 ± 1.09 in the AZ group as compared to 3.20 ± 1.79 in DEX group P value 0.034. The heart rate, mean arterial pressure and oxygen saturation were statistically similar between the two groups, after 45 min. The heart rate was significantly lower in the DEX group as compared to the AZ group. There was no statistical difference in the mean arterial pressure between the two groups either during laryngoscopy or tracheal intubation. Conclusion: Intranasal dexmedetomidine is a better premedication agent in morbidly obese patients than oral alprazolam.

Background: The incidence of difficult laryngoscopy and intubation in obese patients is higher than in the general population. Classical predictors of difficult laryngoscopy and intubation have been shown to be unreliable. We prospectively evaluated indirect mirror laryngoscopy as a predictor of difficult laryngoscopy in obese patients. Materials and Methods: 60 patients with a body mass index (BMI) greater than 30, scheduled to undergo general anesthesia, were enrolled. Indirect mirror laryngoscopy was performed and was graded 1-4 according to Cormack and Lehane. A view of grade 3-4 was classified as predicting difficult laryngoscopy. Additional assessments for comparison were the Samsoon and Young modification of the Mallampati airway classification, Wilson Risk Sum Score, neck circumference, and BMI. The view obtained upon direct laryngoscopy after induction of general anesthesia was classified according to Cormack and Lehane as grade 1-4. Results: Sixty patients met the inclusion criteria; however, 8 (13.3%) patients had an excessive gag reflex, and examination of the larynx was not possible. 15.4% of patients who underwent direct laryngoscopy had a Cormack and Lehane grade 3 or 4 view and were classified as difficult. Mirror laryngoscopy had a tendency toward statistical significance in predicting difficult laryngoscopy in these patients. Conclusions: This study is consistent with previous studies, which have demonstrated that no one individual traditional test has proven to be adequate in predicting difficult airways in the obese population. However, the new application of an old test - indirect mirror laryngoscopy - could be a useful additional test to predict difficult laryngoscopy in obese patients.

Background: There are numerous reports of difficult laryngoscopy and intubation in patients with acromegaly. To date, no study has assessed the application of extended Mallampati score (EMS) for predicting difficult intubation in acromegalics. The primary aim of this study was to compare EMS with modified Mallampati classification (MMP) in predicting difficult laryngoscopy in acromegalic patients. We hypothesized that since EMS has been reported to be more specific and better predictor than MMP, it may be superior to the MMP to predict difficult laryngoscopy in acromegalic patients. Materials and Methods: For this prospective cohort study with matched controls, acromegalic patients scheduled to undergo pituitary surgery over a period of 3 years (January 2008-December 2010) were enrolled. Preoperative airway assessment was performed by experienced anesthesiologists and involved a MMP and the EMS. Under anesthesia, laryngoscopic view was assessed using Cormack-Lehane (CL) grading. MMP and CL grades of I and II were defined "easy" and III and IV as "difficult". EMS grade of I and II were defined "easy" and III as "difficult". Data were used to determine the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MMP and EMS in predicting difficult laryngoscopy. Results: Seventy eight patients participated in the study (39 patients in each group). Both MMP and EMS failed to detect difficult laryngoscopy in seven patients. Only one laryngoscopy was predicted to be difficult by both tests which was in fact, difficult. Conclusion: We found that addition of neck extension did not improve the predictive value of MMP.

Background: Various anatomical measurements and non-invasive clinical tests, singly or in various combinations can be performed to predict difficult intubation. Recently introduced "Upper lip bite test" (ULBT) and "Ratio of height to Thyromental distance" (RHTMD) are claimed to have high predictability. We conducted a study to compare the Predictive Value of ULBT and RHTMD with Mouth opening (Inter-Incisor gap) (IIG), Modified Mallampatti Test (MMT), Head and neck movement (HNM) and Thyromental Distance (TMD) for Difficult Laryngoscopy. Materials and Methods: In this prospective, single blinded observational study, 480 adult patients of either sex, ASA grade I and II were assessed and graded for ULBT, RHTMD, TMD, MMT, IIG, and HNM according to standard methods and correlated with the Cormack and Lehane grade. Results: ULBT and RHTMD had highest sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio, i.e., 74.63%, 91.53%, 58.82%, 95.7%, 31.765 and 71.64%, 92.01%, 59.26%, 95.24%, 8.96 respectively, compared to TMD, MMT, IIG and HNM. Conclusions: ULBT is the best predictive test for difficult laryngoscopy in apparently normal patients but RHTMD can also be used as an acceptable alternative.

Background: Use of McCoy blade laryngoscope avoids the lifting force in the vallecula and theoretically should lead to a lower hemodynamic response related to laryngoscopy and tracheal intubation. The available literature on the topic is conflicting. Materials and Methods: We studied the hemodynamic response to laryngoscopy and tracheal intubation in 60 ASA 1 AND 2 adult patients using either Macintosh or McCoy laryngoscopes. The change in systolic, diastolic, mean arterial pressure, and heart rate (HR) was observed for 10 min post intubation. Arrhythmias and ST changes were also observed. Results: The maximum change in HR was 18.7% in the Macintosh and 7.7% in the McCoy group, and in systolic arterial pressure was 22.9% in the Macintosh and 10.3% in the McCoy group. This difference between groups was significant ( P < 0.0001). The change lasted for a lesser duration in the McCoy group. No arrhythmias or ST changes were observed in either group. Conclusion: Hemodynamic changes with use of McCoy laryngoscope were lesser in magnitude and of shorter duration.

Background: In patients with craniovertebral junction (CVJ) anomalies, the respiratory system is adversely affected in many ways. The sub-clinical manifestations may get aggravated in the postoperative period owing to anesthetic or surgical reasons. However, there is limited data on the incidence of postoperative pulmonary complications (PPCs) and associated risk factors in such patients, who undergo transoral odontoidectomy (TOO) and posterior fixation (PF) in the same sitting. Materials and Methods: Five years data of 178 patients with CVJ anomaly who underwent TOO and PF in the same sitting were analyzed retrospectively. Preoperative status, intraoperative variables, and PPCs were recorded. Patients were divided into two groups depending on the presence or absence of PPCs. Bivariate analysis was done to find out association between various risk factors and PPCs. Multivariate analysis was done to detect relative contribution of the factors shown to be significant in bivariate analysis. P < 0.05 was considered as significant. Results: The incidence of PPCs was found to be 15.7%. Factors significantly associated with PPCs were American Society of Anesthesiologists grade higher than II, preoperative lower cranial nerves palsy and respiratory involvement, duration of surgery, and intraoperative blood transfusion. In multivariate analysis, blood transfusion was found to be the sole contributing factor. The patients who developed PPCs had significantly prolonged stay in ICU and hospital. Conclusion: Patients with CVJ anomaly are at increased risk of developing PPCs. There is a strong association between intraoperative blood transfusion and PPCs. Patients with PPCs stay in the ICU and hospital for a longer period of time.

Purpose: Patients undergoing middle ear surgery experience variable degrees of postoperative nausea and vomiting (PONV) despite prophylaxis and treatment with ondansetron or other 5HT ₃ receptor antagonists. Furthermore vertigo or dizziness are not well controlled perioperatively. Role of betahistine was tested as an add-on to ondansetron in control of PONV and vertigo in middle ear surgery cases. Materials and Methods: We conducted a prospective, randomized, double-blind, placebo controlled study, enrolling one hundred patients undergoing middle ear surgery under local anesthesia into two groups consisting of fifty (n = 50) patients each. Group A patients were given betahistine 16 mg plus ondansetron 8 mg and placebo plus ondansetron 8 mg were given to group B or placebo group, orally 3 hours before starting operation. The incidence of nausea, vomiting, and dizziness was noted during the intraoperative and postoperative 24 hours period. Chi-square test, unpaired 't' test, and Fisher's exact tests were performed for statistical analysis using SPSS version 16 and Open Epi version 2.3.1 softwares. Results: Complete response was obtained in 90% patients in the betahistine group as compared to 66% in the placebo group. Vomiting in the intraoperative and postoperative period was noted in 4% and 8% cases, respectively, in the betahistine group as compared to 18% and 26%, respectively, in the placebo group. Overall, vertigo was 10% versus 32% in betahistine group and placebo group, respectively. Conclusion: Betahistine as an add-on to ondansetron can significantly attenuate PONV and perioperative vertigo, following middle ear surgeries.

Purpose: The lack of adequate perioperative documentation has legal implications and can potentially affect the quality and safety of patient care. Despite the presence of guidelines, the adequacy of perioperative documentation in Australasia has not been adequately assessed. The aim of this study is to assess the adequacy of anesthetic documentation on the pre and intraoperative encounters and to test the hypotheses that documentation is incomplete in the settings of emergency vs. elective procedures, regional vs. general anesthesia, and manual vs. electronic documentation. Materials and Methods: The study was an observational retrospective study in the setting of a 250-bed teaching hospital in metropolitan Adelaide, Australia. The perioperative records of 850 patients were analyzed. A scoring system was designed, based on a policy statement from the Australian and New Zealand College of Anesthetists and a survey of the hospital anesthetists. Scored and categorical data was analyzed using Chi-square test. Numerical data was analyzed using student t-test. The null hypothesis was accepted or rejected at 0.05 significance. Results: There were significant deficiencies in the adequacy of preanesthetic and intraoperative records. This has been shown to be true in all cases. Documentation was found to be poorer in the emergency setting when compared to elective cases (median scores 15 vs. 21 P = 0.03) as well as documentation of airway assessment for cases done solely under regional anesthesia (42 vs. 85%, P = 0.05). There were no significant differences in the adequacy of electronic vs. manual records ( P = 0.92). Conclusion: There are significant deficiencies in the adequacy of perioperative records. This has been shown to be true in all cases, but is especially so in emergency cases and for patients having only regional anesthesia.

Background: To assess the quality of research presentations made in conferences, its success or failure to be published in a peer-reviewed journal is a well-accepted marker. However, there is no data regarding the publication of research presentations made in Indian conferences of anesthesiology. Objective: The primary objective was to determine publication rate of research presented at the largest and best attended national conference in anesthesiology, the Indian Society of Anaesthesiologists' Conference (ISACON), and also compare it with the rate from an international conference American Society of Anesthesiologists (ASA annual meeting) held in the same year. Materials and Methods: All 363 abstracts presented as poster or podium presentations at the ISACON, and an equal number of randomly selected abstracts presented at ASA annual meeting were searched on Pubmed and Google Scholar for their full-text publications in peer-reviewed journals using a standardized search strategy. As secondary observations, abstracts were assessed for completeness by noting certain components central to research methodology. Also, changes between abstract of the presentation and published paper were noted with respect to certain components. Results: The publication rate of presentations at ISACON and ASA meetings was 5% and 22%, respectively. The abstracts from ISACON lacked central components of research such as methods and statistical tests. The commonest change in the full-text publications as compared with the original abstract from both conferences was a change in authorship. Conclusion: Steps are required to augment full-text publication of Indian research, including a more rigorous peer review of abstracts submitted to ISACON to ensure their completeness.

Background: A parental occupation such as anesthesia care provider can involve exposure of the parent to various chemicals in the work environment and has been correlated to skewed offspring sex ratios. Objectives: The objective was to conduct a nation-wide survey to observe (a) whether firstborn offspring sex ratio (OSR) in anesthesia providers is skewed towards increased female offspring, and (b) to identify potential factors influencing firstborn OSR, particularly those relating to the peri-conceptional practice of inhalational anesthesia induction among anesthesia providers. Materials and Methods: After institutional review board approval, a questionnaire was uploaded on SurveyMonkey and sent to anesthesia providers through their program coordinators in United States (US) to complete the survey. Results: The current US national total-population sex ratio is 0.97 male (s)/female with an at-birth sex ratio of 1.05 male (s)/female; comparatively, the results from anesthesia providers' survey respondents (n = 314) were a total OSR of 0.93 male (s)/female ( P = 0.61) with firstborn OSR 0.82 male (s)/female (a 6% increase in female offspring; P = 0.03), respectively. The only significant peri-conceptional factor related to anesthesia providers' firstborn OSR's skew was inhalational induction practice by anesthesia care provider favoring female offspring ( P < 0.01). Conclusion: Based on the results of this limited survey, it can be concluded that anesthesia care providers who practice inhalation induction of anesthesia during the peri-conceptional period are significantly more likely to have firstborn female offspring.

Background: More than 3/4 ^th of Indian population resides in rural areas. The public awareness towards "Anesthesia and Anesthesiologist" is limited even in urban population. There is no data available from rural India on this perspective. Our cross-sectional analysis highlights this lack of public awareness and discusses possible remedies to overcome these limitations. Materials and Methods: Surgical outpatient department of Comprehensive Rural Health Center (CRHC) Ballabgarh, Haryana (model CRHC for Indian health schemes) was screened for 6 months period. A questionnaire divided into 3 parts (Awareness about Anesthesiologist, Consent, Present surgical experience) was filled out for each patient. The patients on the basis of their answers were classified as "aware or unaware," also source of patient information was analyzed. Results: Even with an extremely low threshold, only 36.44% of population could be classified as aware, and commonest source of their information was not anesthesiologist but surgeon (64.32%). 83.6% patients were not aware of contents of pre-operative consent they had signed and further, only 3.4% were aware of anesthesia-related issues. Pain was reported as the most common pre-operative fear and post-operative patient concern. 47.17% patients due to lack of pre-operative counseling were not able to recognize the type of anesthesia and thought they had received both general anesthesia and spinal anesthesia. At the end, after explaining the role of anesthesia for surgery, 99.06% patients presented desire to meet the anesthesiologist beforehand if they were to be operated in future. Conclusion: The rural awareness about anesthesia is extremely low likely because of low literacy rates and lack of pre-operative counseling by anesthesiologist. Both patient and anesthesiologist must understand the importance of consent, as it is not only a legal binding but can eliminate pre-operative factitious fears of patients and can improve patient satisfaction towards surgery.

The usage frequency and scope of supraglottic airway devices in anesthesia has expanded since the original laryngeal mask airway (LMA) prototype was invented by Dr Archie Brain in the early 1980s. Today, anesthesiologists are spoilt-for-choice with more than thirty options. The LMA Classic Excel™ was introduced to anesthesia practice in 2009; designed with an epiglottic elevating bar and a removable airway connector to facilitate tracheal intubation using the LMA as a conduit. We present a case report of a women diagnosed with papillary carcinoma of thyroid, who underwent bronchoscopic assessment of the trachea and subsequent intubation for an en-bloc dissection and removal of thyroid gland through the LMA Classic Excel™.

Various criteria for weaning patients from ventilators in intensive care have been widely published. These criteria are increasingly incorporated into guidelines, protocols, and more recently, care pathways. We present a case where a patient's lungs were ventilated for 4 days with an infective exacerbation of chronic obstructive pulmonary disease (COPD). We successfully weaned off mechanical ventilation and rapidly extubated the patient's trachea utilizing deep sevoflurane anesthesia. Published weaning indices suggest that this would have been an inappropriate course of action at the time. However, our patient clearly benefited and avoided the need for tracheostomy and prolonged ventilation.

We present a case of severe autonomic dysreflexia (AD) progressing to cardiac arrest and death under isoflurane anesthesia. Though AD in chronic cervical spine injury is a common entity, occurrence of such an event in the stage of flaccid paralysis in lower dorsal spinal cord injury is rare, especially under general anesthesia. Manipulation of urinary bladder catheter under light plane of isoflurane anesthesia might be the precipitating factor. Increasing concentration of isoflurane failed to abort the episode or might have aggravated it. High level of suspicion and vigilance is necessary to prevent, diagnose and treat such a condition.

Evaluation of the degree of neuromuscular blockade by the surgeon using clinical criteria alone is unreliable. We report a case of prolonged neuromuscular blockade lasting 5.5 h, where an additional intra-operative dose of neuromuscular relaxant was given at the request of the surgical team. Possible causes of prolonged neuromuscular antagonism are discussed, as is the importance of neuromuscular assessment prior to the administration of additional neuromuscular blocking agents when receiving a surgeon request for additional neuromuscularblockade.

Valvular heart disease in systemic lupus erythematosus (SLE) is associated with substantial morbidity and mortality. Current therapy includes symptomatic measures and valve replacement. SLE can present major challenges because of accrued organ damage, coagulation defects and complex management regimes. The peri-operative goals are to maintain strict asepsis, avoid use of nephrotoxic drugs and thereby renal insult, and to promote early ambulation post-operatively.

Tracheomalacia is a rare condition characterized by weakness of tracheobronchial cartilaginous bridges. Severe weakness results in tracheal collapse during inspiration, obstructing normal airflow. Tracheomalacia may also be associated with esophageal atresia, tracheoesophageal fistula, and gastroesophageal reflux. Aortopexy is an established surgical procedure for treatment of severe tracheomalacia. A 2-month-old boy was scheduled for aortopexy. He had already undergone repair of tracheoesophageal fistula and had failed multiple attempts at extubation. Intraoperative flexible fiberoptic bronchoscopy was performed to guide the amount and direction of aortopexy for assuring the most effective tracheal decompression. Since tracheomalacia is best assessed in a spontaneously breathing patient, it was an anesthetic challenge to maintain an adequate depth of anesthesia while allowing the patient to breathe spontaneously. Throughout the intraoperative period, SpO ₂ remained ≥96%. Following the procedure, the trachea was extubated and patient was able to breathe normally.

Despite advances in various modalities of management, subarachnoid hemorrhage (SAH) continues to be associated with high mortality, which is further increased by associated comorbidities. Aortic stenosis (AS) is one such disease which can further complicate the course of SAH. We recently managed a known patient of severe AS, who presented with aneurysmal SAH. Patient was planned for eurovascular intervention. With proper assessment and planning, patient was managed with favorable outcome despite the restrictions faced in the neurovascular intervention laboratory.

Morquio-Brailsford syndrome is a type of mucopolysaccharidoses. It is a rare disease with features of short stature, atlantoaxial instability with risk of cord damage, odontoid hypoplasia, pectus carinatum, spine deformities, hepatomegaly, and restrictive lung disease. Neck movements during intubation are associated with the risk of quadriparesis due to cervical instability. This, along with the distortion of the airway anatomy due to deposition of mucopolysaccharides makes airway management arduous. We present our experience in management of difficult airway in a 3-year-old girl with Morquio-Brailsford syndrome posted for magnetic resonance imaging and computerized tomography scan of a suspected unstable cervical spine. As utmost sagacity during intubation is required, the child was intubated inside operation theatre in the presence of experienced anesthesiologists and then shifted to the peripheral location. Intubation was done with an endotracheal tube railroaded over a pediatric fibreoptic bronchoscope passed through the lumen of a classic laryngeal mask airway, keeping head in neutral position.

We report two cases of massive tongue edema in routine palatoplasty. All patients had uneventful recovery. We postulated that the macroglossia was secondary to ischemia and venous congestion after prolonged use of Killner Dott mouth gag with slotted tongue blade exaggerated by hyperextension of neck and Trendelenberg position.