In Reply:-In cases 1 and 2, the laryngeal mask airway (LMA) was inserted by an anesthetist who routinely use this technique. Insertion was performed in both cases with the standard technique described and recommended by Brain. [1] The cuff was fully deflated before insertion, and the LMA was not held during inflation.

After placement and cuff inflation, signs of correct placement were checked, (i.e., forward projection of the thyroid and cricoid cartilages, short tubing protruding from the mouth, black line facing cranially, no audible sound of obstruction, and no difficulty in manual ventilation). I agree with Drs Bapat and Verghese that a misplacement could not be completely eliminated as correct position was not confirmed by fiberscopy.

However, if a malposition had resulted in a superior laryngeal nerve palsy, this could not explain other symptoms (i.e., severe dysphagia and laryngeal incompetence lasting several months). Progressive worsening of dysphonia and dysphagia and the duration of symptoms are in favor of an ischemic inflammatory reaction located in the posterior cricoid region.

I agree that silicon spray used for lubricating the LMA in case 2 may have degraded the structure of the material, resulting in lower compliance of the cuff and higher pressure transmitted on the pharyngeal mucosa. Whatever were the exact causes, the most probable hypothesis is an excessive pressure exerted against the pharyngeal wall. This justifies monitoring the intracuff pressure and limiting this pressure to 60 cm H2O [2] or to the “just seal pressure.”[3]

Dr. A. M. Cros

Department of Anaesthesiology; Hopital Pellegrin-Enfants; Place Amelie Raba-Leon; 30076 Bordeaux; France

Brain AIJ: The Intavent Laryngeal Mask. Instruction Manual. 2nd ed, 1993.
Brain AIJ: Pressure in laryngeal mask airway cuffs. Anaesthesia 1996; 51:605.
Brimacombe J, Berry A: Optimal intra-cuff pressures with the laryngeal mask (Letter). Br J Anaesth 1996; 77:295-6.