We thank Drs. Taxak and Gopinath for their valuable contribution in response to our article.1Failure of supraglottic airway devices occurs because of either failed insertion or failed ventilation, despite successful insertion. In case of the i-gel™ (Intersurgical Ltd., Wokingham, Berkshire, United Kingdom), insertion may fail because of the inability to pass the device between the front teeth, the tongue, or the pharyngeal curvature. Overall, the inability to insert the i-gel™ is quite a rare event (1.3%).†As Drs. Taxal and Gopinath point out correctly that the bulky design of the i-gel™ with its large airway opening may cause entrapment of the tongue. We agree that digitally pushing the tongue out of the way may solve the problem. However, many anesthesiologists would be reluctant to put their finger into the mouth of a patient who has not received muscle relaxation. A simple tongue retractor might be used too.

In addition, clinicians need to be aware of the fact that the i-gel™ may not only push the tongue down, impeding successful insertion, but also displace the base of the tongue after insertion. That may lead to protrusion of the tongue from the mouth, trapping its tip between the lower teeth and the integral bite block of the i-gel™ (see fig. 1). In fact, in a large prospective evaluation of nearly 2,000 cases, we documented a patient who suffered from prolonged bilateral numbness at the tip of the tongue because of that entrapment in an otherwise short and uneventful anesthesia.† That might have happened with the use of other supraglottic airway devices too. We thus strongly recommend checking the tongue position in every patient after successful i-gel™ insertion.

Fig. 1. Tongue is trapped between lower teeth and i-gel™ (Intersurgical Ltd., Wokingham, Berkshire, United Kingdom) (simulated photo).

Fig. 1. Tongue is trapped between lower teeth and i-gel™ (Intersurgical Ltd., Wokingham, Berkshire, United Kingdom) (simulated photo).

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*University Hospital Bern, University of Bern, Bern, Switzerland. robert.greif@insel.ch

Theiler LG, Kleine-Brueggeney M, Kaiser D, Urwyler N, Luyet C, Vogt A, Greif R, Unibe MM: Crossover comparison of the laryngeal mask supreme and the i-gel in simulated difficult airway scenario in anesthetized patients. Anesthesiology 2009; 111:55–62