Dear Editor,

I read with interest “Difficult Airway in a patient with cleft palate by Narayanan et al1. I congratulate the authors for managing the airway in a tricky situation. To summarize; the situation was a difficult intubation caused by a tongue tie but an easy ventilation. The tracheal intubation was successfully done after releasing the tongue tie. However there are some fundamental safety concerns in this management.

Firstly, according to the authors themselves “Tongue tie theoretically may be a blessing in disguise in maintaining the upper airway as the tongue is prevented from falling back”. Herein lies the concern. There is significant risk of making the mask ventilation difficult by release of tongue tie as the tongue may fall back. In presence of an anticipated intubation difficulty, this could make the situation worse. One may end up losing the airway control totally. Therefore routine release of tongue tie in such cases should be reconsidered.

Secondly, there are numerous case reports of use of molar approach of intubation in these patients which appear to be effective as well as safe2. The right molar approach for laryngoscopy has been described for intubation of patients with a difficult airway. It can be used as paraglossal or retromolar technique. In this technique, a straight blade laryngoscope is introduced from the right corner of mouth along the groove between the tongue and the tonsil, using leftward and anterior pressure to displace the tongue to the left. The blade is advanced and its tip is made to pass posterior to the epiglottis. Rotation of the neck and manipulation of the cricoid cartilage have been suggested to improve the laryngoscopic view3. Therefore we should try intubation using molar approach first rather than taking a hasty decision to release the tie as it may worsen the airway management.