To the Editor:-The laryngeal mask airway (LMA) provides an alternative technique for managing difficult airway scenarios. [1,2] We would like to report a case of compromised airway resulting from an extensive severe postburn contracture and its subsequent management.
During a medical humanitarian mission to the West Bank of Palestine, a 32-year-old woman, ASA physical status 2, presented with severe extensive neck contracture that affected the neck, the chin, and the lower lip. The contracture was a result of an untreated partial and full-thickness thermal burn because of the ignition of clothing during a house fire. Surgical reconstruction had been scheduled 1 year previously, but the operation was cancelled because of failure of conventional orotracheal intubation. Because of psychological disturbances and apparent limited intelligence, attempts to establish satisfactory rapport with the patient was unsuccessful. Consequently, we did not believe that an awake blind nasotracheal intubation was an option. [2] Also, the retrograde technique (translaryngeal-guided intubation) was not attempted because of anatomic deformity resulting from the extensive neck contracture.
After preoxygenation, anesthesia was induced with propofol and fentanyl, and the lungs were ventilated manually with oxygen and halothane by a size 4 face mask without particular difficulty. Laryngoscopy with a Macintosh laryngoscope (blade 3 and 4) was attempted twice, but the larynx could not been seen. Because the facilities for an alternative intubation (e.g., new laryngoscope blades, illuminating intubating stylets, flexible fiberscope) were not available, a LMA, size 3, was requested. The device was passed easily, and a patent airway was obtained. The patient underwent an uneventful 3-h inhalation anesthetic with spontaneous ventilation. The chin was released from the chest, and the defect, which included all the anterior and lateral neck, was covered with thick partial thickness skin grafts. The LMA was left in place until the patient regained full consciousness, and the recovery was uneventful.
Vasilios Dimitriou, M.D., D.E.A.A.
Gregory S. Voyagis, M.D.
Antigone Malefaki, M.D.
Department of Anesthesiology
Demosthenis Tsoutsos, M.D.
Department of Plastics; G. Gennimatas General Hospital
154 Mesogion Avenue.; GR-115 27 Athens; Greece
(Accepted for publication February 5, 1997.)
