To the Editor,

We read with interest the Prabhakar et al's letter (₁) and congratulate them for their safe airway management with fall back plan in place. We would like to comment on few issues and would like to highlight the fact that this is complimentary to the letter.

It is not clear from the letter whether the difficulty was predicted for ventilation and intubation other than the presence of the huge occipital swelling i.e a higher Mallampatti class or a shorter thyromental distance etc. Although patient had a large occipital mass, the gap between the swelling and the neck probably allowed some range of neck movement. We appreciate the fact that huge occipital swelling can cause difficulty in securing an airway.

In our opinion every anesthesiologist should be competent to intubate a patient in the lateral position and we are impressed with the authors for their competency. During our training, we were specifically encouraged to consolidate our intubating skills in lateral position with regular training in elective straight forward cases. We believe such training is important to deal with situations like this case. Probably the lack of training and unfamiliarity of the airway management in lateral position lead to failure in tracheal intubation in McCaul et al's trial (₂) and Adachi et al's case series(₃).