Failure of LMA in a child with normal airway because of large tonsil – An unrecognized cause: case report
A Srivastava, S Kumar, R Raman, P Gupta
A Srivastava, S Kumar, R Raman, P Gupta. Failure of LMA in a child with normal airway because of large tonsil – An unrecognized cause: case report. The Internet Journal of Anesthesiology. 2008 Volume 21 Number 1.
The Laryngeal Mask Airway (LMA) is a supraglottic airway device that was invented by Dr. Archie Brain, a British anesthetist1. The Classic LMA is the original LMA and is considered a general purpose device. It has been used extensively for different general surgical, urologic, orthopedic and ophthalmic procedures. It has also proved useful in place of endotracheal intubation in difficult airway situations in children. It has also gained wide usage for airway resuscitation and rescue .
An 8 year child (hospital no: 28977) was posted for urethroplasty in plastic surgery O.T. in our S.S. hospital, IMS, BHU. He had mallampati class I with mouth opening 5 cm. flexion and extension movement were within normal limit. We planned general anaesthesia with classic LMA for him. After attaching ECG, NIBP, SpO2, inj. Glycopyrrolate 0.2 mg, Ondansetron 2.5mg IV, inj pentazosine 15mg iv was given. After preoxygenaton for 3 minutes inj. Propofol was given till loss of verbal command. Insertion of Classic LMA #2.5 was tried. After failure of two attempts LMA#2.0 was tried, but it could not be inserted also, after giving mask ventilation conventional laryngoscopy was performed. Then we found that his right tonsil (palatine) was enlarged which was preventing the LMA to go inside. Inj vecuronium 2.5mg iv was given and the child was ventilated for 2.5 minutes and then intubated with no 6.0 endotracheal tube easily.
The laryngeal mask airway (LMA) is useful in the management of airway even in cases of difficult airways 3 . There are very few cases of failure of LMA even in a “cannot ventilate, cannot intubate” scenario 45 . One report of failure of LMA in CVCI scenario, was published by Samir K. Patel et al 6 .We report that case as a failure to insert the LMA in a child having normal airway posted for a routine surgery.
The laryngeal mask airway (LMA) has challenged the assumption that tracheal intubation is the only acceptable way to maintain a clear airway and provide positive pressure ventilation. Brain designed LMA as “an alternative to either endotracheal tube or the facemask for use with either spontaneous or positive pressure ventilation.” 1 . As LMA has many advantages over ETT like more haemodynamic stability, less sympathetic stimulation, lower incidence of coughing during extubation and lower incidence of postoperative sore throat 2 . These advantages made LMA more popular than ETT specially in paediatric cases.
Insertion of LMA is easier and needs no laryngoscopy, that’s why lot of cases is being done in supraglottic devices like LMA. Easy method of insertion without laryngoscopy made LMA a popular method to manage the cases of difficult intubation.
But is insertion of LMA always easier than intubation? This case report tells that as LMA is useful in cases of failed intubation , intubation may be useful in cases of failure of LMA. In children the possibility of enlarged tonsils should be kept in mind during use of LMA.