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 Table of Contents  
Year : 2017  |  Volume : 22  |  Issue : 1  |  Page : 22-25

Awake insertion of proseal laryngeal mask airway: A technique for cases of fixed flexed neck deformity

Department of Anaesthesiology, Lokmanya Tilak Municipal Medical College, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India

Date of Web Publication14-Mar-2017

Correspondence Address:
Balasaheb Tukaram Govardhane
403, Purnima Paradise, Plot No 72, Sector 20, Kharghar, Navi Mumbai - 410 210, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmgims.jmgims_37_16

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Fixed flexion deformity of the neck due to postburn contracture results in the nonalignment of oral, pharyngeal, and laryngeal planes for intubations. Airway management is a challenge to anesthesiologist in these cases. Awake fiberoptic intubation if available is the gold standard in such cases. The design of ProSeal laryngeal mask airway (LMA) is such that it provides a good alternative to the endotracheal tube and its insertion does not require the visualization of the vocal cords. We present the successful airway management of a patient with severe fixed flexion deformity of the neck by an awake ProSeal LMA insertion.

Keywords: Awake ProSeal, difficult airway, neck conracture

How to cite this article:
Govardhane BT, Patkar GA, Parikh DA, Tendolkar BA. Awake insertion of proseal laryngeal mask airway: A technique for cases of fixed flexed neck deformity. J Mahatma Gandhi Inst Med Sci 2017;22:22-5

How to cite this URL:
Govardhane BT, Patkar GA, Parikh DA, Tendolkar BA. Awake insertion of proseal laryngeal mask airway: A technique for cases of fixed flexed neck deformity. J Mahatma Gandhi Inst Med Sci [serial online] 2017 [cited 2021 Dec 6];22:22-5. Available from: https://www.jmgims.co.in/text.asp?2017/22/1/22/202005

  Introduction Top

Postburn contracture (PBC) of the neck results in decreased oropharyngeal and submandibular space, limited atlantooccipital joint extension, and heavily fibrosed neck. It usually leads to difficult mask ventilation, laryngoscopy, and intubation. In severe cases, there is a potential of losing the airway under anesthesia. These cases are ideally managed along the awake limb of the difficult airway algorithm. The options range from awake fiberoptic to release of contractures under local anesthesia (LA).[1]

ProSeal laryngeal mask airway (PLMA) is considered to be a suitable alternative to endotracheal tube (ETT).[2] The additional dorsal cuff gives a good periglottic seal and permits higher airway pressures during ventilation without leak. The drain tube protects against aspiration. We present the successful management of a patient with severe fixed flexion deformity of the neck with awake PLMA. Written consent was obtained from the patient to publish this case report.

  Case Report Top

A 40-year-old male presented to the plastic surgery department of our hospital for release of PBC of the neck [Figure 1]. Preoperative examination showed fixed flexion deformity of the neck, with the involvement of chin, left angle of the mandible, and part of lower lip in the contracture with body mass index 22.95. Although mouth opening was adequate [Figure 2], the posterior part of the pharynx could not be visualized; thus, Mallampati classification could not be applied. Barring the contracture on right axilla, the rest of the general, systemic, and laboratory investigations were normal. X-ray neck lateral view showed decreased oropharyngeal space with a markedly acute angulation of airway beyond the tongue. Ear-nose-throat assessment of the oro- and naso-pharynx before surgery to rule out inhalation injury of airway was normal. We planned awake insertion of PLMA, followed by induction of general anesthesia. The patient was explained about the difficult airway due to the deformity, and a good rapport was established. The procedure of upper airway anesthesia and awake swallowing of PLMA was explained. Written informed consent was obtained.
Figure 1: Fixed flexion neck deformity

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Figure 2: Adequate mouth opening

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After confirming adequate fasting, in the operation theater, the patient was put on standard monitoring and intravenous access was secured. Equipment for difficult airway was kept ready fiberoptic bronchoscope (FOB) which was not available owing to technical reasons. The surgeon was ready for release of neck contracture or tracheostomy in case of eventuality. The patient was premedicated with intravenous glycopyrrolate and 1 mg midazolam. Oropharyngeal airway was anesthetized with 1 ml 4% lignocaine nebulization and 5 ml 2% lignocaine gargles. After verbal confirmation of anesthesia, the patient was asked to swallow the PLMA no. 4 without introducer in the sitting position and was assisted by an experienced anesthesiologist, offering a gentle pressure on the ProSeal during the swallowing [Figure 3]. The PLMA slipped comfortably inside the mouth; there were good air blast and capnogram from the LMA tube. The cuff was inflated with 30 ml of air. The nasogastric tube was inserted easily and square wave capnograph confirmed adequate ventilation. Once measurement of expired tidal volume (Vt) on anesthesia machine confirmed that there was no pericuff gas leak, anesthesia was induced with propofol [Figure 4]. Anesthesia was maintained with N2O and O2, atracurium, propofol, and fentanyl with controlled mode of ventilation. Intraoperative period was uneventful. At the end of surgery, the PLMA was removed when patient was awake and shifted to Postanesthesia Care Unit.
Figure 3: ProSeal laryngeal mask airway self-insertion with assistance in sitting position

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Figure 4: Proseal LMA in situ

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  Discussion Top

PBC of the neck in our case could be classified as type 3 neck contracture,[3] i.e., thick anterior mentosternal contracture with neck in fixed flexed position and the chin restrained down to the trunk. Maintaining airway during anesthesia by triple maneuver would have been impossible, thus exposing the patient to the grave risk of hypoxia, hypercarbia. The safest way in such cases is to secure the airway with the patient awake.

The release of contracture [4] under LA though possible was not contemplated as type 3 and more severe PBCs required extensive dissection.[3] It would have been time-consuming, also injection through a thick scar (more than a year old) is very painful, the depth and plane of injection cannot be assessed because of the thickness of contracture scar. Sometimes, even after release, intubation may not be successful in all cases.[3] In our setup, surgeons are more comfortable releasing contracture after airway is secured as they believe that dissection is compromised under LA.

Retrograde intubation was difficult as our patient neck contracture type 3 that made difficulty in giving transtracheal and superior laryngeal nerve block. Awake blind intubation in a fixed flexion deformity is difficult as head and neck have to be manipulated for its success. Besides, regional airway blocks are difficult to perform and the patient keeps struggling as the ETT approaches the glottis due to intact airway reflexes.

Use of awake fiberoptic intubation (FOB) though a gold standard for intubation in such cases [1],[5] has its own limitations. Sometimes, acute flexion deformity of the neck may cause difficulty in passing ETT through the cords.[6],[7] Furthermore, there are few reports [8],[9] which had reported loss of airway in awake patients under topical anesthesia when fiberoptic intubation was planned, and in one of those cases,[8] the lost airway was rescued using LMA classic, followed by tracheostomy. We could not consider FOB due to its unavailability.

We planned awake PLMA insertion to secure airway with an alternative backup plan of contracture release under LA (tumescent anesthesia),[10] followed by direct laryngoscopy and intubation. Supraglottic airway devices have revolutionized the management of difficult airway. Many authors have described the use of these devices in PBC of the neck surgery under anesthesia.[11],[12] Awake insertion of intubating LMA (ILMA)[7] could have been considered. However, there is a chance of failed intubation in spite of correct ILMA placement due to severe neck contracture.[13] Although awake intubation using CTrach LMA [14] has been reported in difficult airways (not PBC), we could not consider this option due to its unavailability. We preferred ProSeal as it can be considered an effective alternative to ETT during positive pressure ventilation.[2] The PLMA maintains adequate ventilation at significantly lower Vts and peak pressures without increasing raw and has minimal hemodynamic variations as compared to ETT. The PLMA has lower incidence of postoperative cough, blood staining, and sore throat as compared to ETT.

The prerequisite for successful placement is adequate mouth opening and patient cooperation which was developed by good counseling and good topical airway anesthesia. We used a careful balance of sedation with nebulized lignocaine and gargles to achieve a calm and spontaneously breathing patient with nonreactive airway. A topical anesthesia of the airway to unsedated patient undergoing awake fiberoptic intubation or LMA may have applications, where avoidance of sedation is desirable. It produced good conditions and cooperation for procedures. Lidocaine pharmacokinetics is complex; absorption varies with site and mode of delivery and the use of anticholinergic drugs. It has been estimated that only 8%–12% of lidocaine given by a nebulizer will reach the airway as a result of wastage. British Thoracic Society recommends that the total dose of lidocaine applied during bronchoscopy should be limited to 8.2 mg/kg.[15]

The limitations of ProSeal LMA during surgery were displacement due to neck dissection and subsequent air leak. However, gastric tube in situ acts as anchor to hold it in situ and gastric distension because of air avoided.

We did anticipate difficulty in placement due to the acute angulation of oral and pharyngeal axis; however, with the patient himself swallowing the PLMA like his regular food, the procedure became relatively simple and took <10 min.

  Conclusion Top

Awake insertion of ProSeal LMA can be considered for cases of fixed flexion deformity of the neck in situ ations where FOB is not available, provided mouth opening is adequate. Thorough understanding of the difficult airway and good preoperative rapport along with proper topical upper airway anesthesia made this procedure successful.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251-70.  Back to cited text no. 1
Saraswat N, Kumar A, Mishra A, Gupta A, Saurabh G, Srivastava U. The comparison of Proseal laryngeal mask airway and endotracheal tube in patients undergoing laparoscopic surgeries under general anaesthesia. Indian J Anaesth 2011;55:129-34.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
Onah II. A classification system for postburn mentosternal contractures. Arch Surg 2005;140:671-5.  Back to cited text no. 3
Park CD, Lee HK, Yim JY, Kang IH. Anesthetic management for a patient with severe mento-sternal contracture: Difficult airway and scarce venous access – A case report. Korean J Anesthesiol 2013;64:61-4.  Back to cited text no. 4
Sahajanandhan R, Saravanan PA, Ponniah M, Jacob JI, Gupta AK, Nambi GI. Post burn contracture neck with extreme microstomia and fibrosed obliterated nose – A unique airway challenge. J Anaesth Clin Pharmacol 2010;26:267-9.  Back to cited text no. 5
Asai T, Shingu K. Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: Incidence, causes and solutions. Br J Anaesth 2004;92:870-81.  Back to cited text no. 6
Kumar R, Prashast, Wadhwa A, Akhtar S. The upside-down intubating laryngeal mask airway: A technique for cases of fixed flexed neck deformity. Anesth Analg 2002;95:1454-8.  Back to cited text no. 7
Shaw IC, Welchew EA, Harrison BJ, Michael S. Complete airway obstruction during awake fibreoptic intubation. Anaesthesia 1997;52:582-5.  Back to cited text no. 8
Ho AM, Chung DC, To EW, Karmakar MK. Total airway obstruction during local anesthesia in a non-sedated patient with a compromised airway. Can J Anaesth 2004;51:838-41.  Back to cited text no. 9
Sharma R. Tumescent anaesthesia for post burn contracture release. Indian J Anaesth 2010;54:579-80.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
Singh J, Yadav MK, Marahatta SB, Shrestha BL. Randomized crossover comparison of the laryngeal mask airway classic with i-gel laryngeal mask airway in the management of difficult airway in post burn neck contracture patients. Indian J Anaesth 2012;56:348-52.  Back to cited text no. 11
[PUBMED]  Medknow Journal  
Singh S, Asthana V, Payal YS, Agrawal S, Singh DK, Srivastava N. Airway management in fixed flexion deformity using an alternative method of ILMA insertion. Indian J Anaesth 2008;52:440-2.  Back to cited text no. 12
  Medknow Journal  
Kumar B, Vadaje K, Sethi S, Singh A. Failed intubating laryngeal mask airway-guided blind endotracheal intubation in a severe postburn contractured neck patient. Acta Anaesthesiol Belg 2011;62:95-9.  Back to cited text no. 13
López AM, Valero R, Pons M, Anglada T. Awake intubation using the LMA-CTrach in patients with difficult airways. Anaesthesia 2009;64:387-91.  Back to cited text no. 14
Williams KA, Barker GL, Harwood RJ, Woodall NM. Combined nebulization and spray-as-you-go topical local anaesthesia of the airway. Br J Anaesth 2005;95:549-53.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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