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National Journal of Maxillofacial Surgery
 
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Table of Contents
LETTER TO EDITOR
Year : 2014  |  Volume : 5  |  Issue : 2  |  Page : 248-249  

Modified mask ventilation in post rhinoplasty patient


1 Department of Anaesthesia, Gian Sagar Medical College, Banur, Patiala, Punjab, India
2 Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication10-Apr-2015

Correspondence Address:
Rudrashish Haldar
Department of Anaesthesia, Gian Sagar Medical College, Banur, Patiala, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-5950.154855

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How to cite this article:
Bajwa SS, Haldar R, Kaur J, Samanta S. Modified mask ventilation in post rhinoplasty patient. Natl J Maxillofac Surg 2014;5:248-9

How to cite this URL:
Bajwa SS, Haldar R, Kaur J, Samanta S. Modified mask ventilation in post rhinoplasty patient. Natl J Maxillofac Surg [serial online] 2014 [cited 2021 May 9];5:248-9. Available from: https://www.njms.in/text.asp?2014/5/2/248/154855

Sir,

Mask ventilation (MV) is a fundamental skill which the anesthesiologists possess and practice routinely for management of the airway. The ability to successfully mask ventilate a patient can prove to be a life-saving maneuver whereas inability to do so may spell a disaster. We encountered a patient who had previously undergone forehead flap rhinoplasty and was scheduled for flap separation. Due to anatomical complexities, a difficult mask ventilation was anticipated [Figure 1]. The complications related to difficult mask ventilation were fully explained to the patient and written consent was obtained for reporting the same. Here we report regarding this patient with anticipated difficult mask ventilation where the maneuver was carried out with a modified approach.

A 60-year-old male patient with history of fall leading to posttraumatic loss of soft tissue over nose, columella, and exposed alar cartilage underwent forehead flap rhinoplasty on the day of injury. After 3 weeks, the patient was posted for flap separation. According to records and history given by the anesthesiologist who delivered anesthesia during the previous surgery, airway management had not posed any problem (Mallampatti Class II, Cormack and Lehane Grade II) and the patient could be intubated easily. However, after induction, conventional ventilation would have been impossible in this patient as the forehead flap was loose and friable and undue pressure over it would have caused the dislodgement of the graft aggravating the cosmetic deformity. Keeping the difficult airway cart ready, a size 2 anatomical face mask was taken and was placed in the reversed position over the mouth of the patient after inserting a Guedel's airway [Figure 2]. The area of the graft was carefully padded and taped to avoid inadvertent injury. Feasibility of MV was checked in this position and after confirming adequacy of MV, succinylcholine was administered, and the patient ventilated and intubated. Rest of the surgical and anesthetic course was uneventful.
Figure 1: Postrhinoplasty patient with forehead flap

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Figure 2: Modified method of mask ventilation using an inverted anatomical face mask

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Disfigured or dismantled facial anatomy as in facial fractures, dislocations, injuries, burns, lesions, etc., can complicate successful airway management. [1],[2] This necessitates planning for alternate techniques to achieve successful mask ventilation. After reviewing the relevant literature, we came across the use of laryngeal mask airway (LMA) and fiber-optic intubation in a similar case. [3] In our case, placement of the LMA would have encroached upon the surgical field. Sethi et al., [4] also reported a similar technique of mask ventilation whereby a pediatric mask was employed to ventilate a patient with nasal tumor. Instead of circular transparent mask, we had used an anatomical mask (size 2), the broad base of which provided a larger area with which we could cover the mouth and area around the vestibule properly. Additionally, to enable proper mask ventilation, a Guedels airway was also inserted by us. The patient was bearded which further augmented the anticipated difficulty in MV as beard by itself is an independent predictor of difficult mask ventilation. [5] Thus the difficulty of mask ventilating the patient successfully in the presence of a unstable and friable patch over the bridge of the nose was successfully circumvented using a modified approach for mask ventilation. Awake fiber-optic intubation would have been ideal in these conditions. However, the previous records and history of an uncomplicated airway were a safety buffer for us which prompted us to proceed with this maneuver while keeping the difficult airway adjuncts ready and we were successful in our airway management efforts.

 
   References Top

1.
Bajwa SJ, Kaur J, Singh A, Singh G. Postburn facial contractures in pediatric patients: Challenging aspects of difficult airway management. Int J Health Allied Sci 2012;1:186-9.  Back to cited text no. 1
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2.
Bajwa SS, Panda A, Bajwa SK, Singh A, Parmar SS, Singh K. Anesthetic and airway management of a child with a large upper-lip hemangioma. Saudi J Anaesth 2011;5:82-4.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Shimosaka M, Hashimoto M, Kouchi A, Shibutani K. A case of difficult mask ventilation and intubation due to giant nasal tip tumor. J Jpn Soc Clin Anesth 2004;24:604-7.  Back to cited text no. 3
    
4.
Sethi S, Arora V, Bhagat H, Sharma A. Use of paediatric face mask for adult ventilation in a patient with nasal tumour. Indian J Anaesth 2010;54:75-6.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O'Reilly M, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology 2006;105:885-91.  Back to cited text no. 5
    


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