CASE REPORT


https://doi.org/10.5005/jp-journals-10049-2004
Journal of Research and Innovation in Anesthesia
Volume 7 | Issue 1 | Year 2022

Role for Pre-emptive Analgesia to Increase the Accuracy of Airway Assessment in Patients having Painful Mouth Opening: A Case Report


Amarjeet Kumar1https://orcid.org/0000-0002-4272-5750, Chandni Sinha2https://orcid.org/0000-0002-4107-2671, Ajeet Kumar3https://orcid.org/0000-0002-1464-6684, Poonam Kumari4https://orcid.org/0000-0003-0118-2187, Kritika Singh5https://orcid.org/0000-0001-6910-4631, Gayatri D Sagdeo6https://orcid.org/0000-0002-4799-2727

1Department of Trauma & Emergency, All India Institute of Medical Sciences, Patna, Bihar, India

2-6Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India

Corresponding Author: Chandni Sinha, Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India, Phone: +91 7250333148, e-mail: chandni.doc@gmail.com

ABSTRACT

Careful preoperative evaluation and planning is essential to prevent airway-related morbidity and mortality during induction of anesthesia. According to previous studies, predictors of difficult airway include Mallampati III, limitation of jaw protrusion, male sex, presence of teeth, limited neck extension, and reduced thyromental distance. There are no clear-cut guidelines regarding application of difficult airway predictors in patient having painful mouth opening. In this case report, we have described our experience of pre-emptive analgesia to increase the accuracy of airway assessment in patient having painful mouth opening.

How to cite this article: Kumar A, Sinha C, Kumar A, et al. Role for Pre-emptive Analgesia to Increase the Accuracy of Airway Assessment in Patients having Painful Mouth Opening: A Case Report. J Res and Innov Anesth 2022;7(1):25-26.

Source of support: Nil

Conflict of interest: None

Keywords: Airway management, Analgesia, Fentanyl, Mucormycosis

INTRODUCTION

Careful preoperative evaluation and planning is essential to prevent airway related morbidity and mortality during induction of anesthesia.1 Difficult airway (DA) has been defined as “the clinical situation in which a conventionally trained anaesthesiologist experiences difficulty in face mask ventilation of the upper airway, difficulty in tracheal intubation, or both.”2 Predictors of difficult airway include Mallampati III, limitation of jaw protrusion, male sex, presence of teeth, limited neck extension, and reduced thyromental distance. Here we describe a case of painful mouth opening in which preoperative airway assessment was facilitated using analgesics (fentanyl 2 mcg/kg). This case report has been prepared in accordance with CARE guideline. Written and informed consent for publication was obtained from the patient.

CASE DESCRIPTION

A 70-year-old female, BMI= 23 kg/m2 was scheduled for open surgical debridement of right-sided rhinocerebral mucormycosis. She had been diagnosed with COVID-19, 6 weeks back for which she was put on steroids. Though she had recovered from COVID, she had developed rhinocerebral mucormycosis, for which she was undergoing treatment (10 mg/kg/day for the last 2 weeks). On examination, the airway examination revealed restricted mouth opening: (1 Finger Breadth) which led to a higher grading of Mallampati score (MP IV). The other parameters were: thyromental distance (thyroid incision distance more than 4.5 cm), normal neck extension, and mandibular elevation (upper lip bite test I degree).

Fentanyl (2 mcg/kg) was given to relieve the muscle spasm which increased to mouth opening to 2.5 finger breadth. Mallampati grading improved to II thereafter. After shifting the patient to operating room, standard ASA monitors were attached and base line vitals noted. An intravenous line was secured and infusion of balanced salt solution was started as maintenance fluid. Anestheia was induced with injection propofol 2 mg/kg and vecuronium 0.1 mg/kg. There was no difficulty in mask ventilation or intubation. The airway was secured with a 7.5 mm (ID) endotracheal tube without use of aided device for difficult airway management. Anesthesia was maintained with oxygen, air, and isoflurane. Surgery lasted for 3 hours and was uneventful. Patients trachea was extubated successfully and she was shifted to postoperative ward.

DISCUSSION

The probability of difficult mask ventilation has been estimated to be 2.7% and of difficult mask ventilation with difficult laryngoscopy to be 1.69%.3 Among the various predictors of difficult airway, Mallampati score remains the most commonly used. It is a graded 4-level pictorial scale created to predict difficult intubation before general anesthesia and is routinely used in operating room worldwide.4 This score has been extrapolated outside of the operating room to procedural sedation, with a number of specialty societies recommending it as a routine screening element. Painful mouth opening during preoperative airway examination affects the difficult airway predictors and gives a false impression of restricted airway. Difficult airway predictor applied in case of restricted airway due to anatomical defect (cleft lip and palate, micrognathia, cranio-carpotarsal dysplasia, epidermolysis bullosa, scleroderma, oral submucous fibrosis, Plummer-Vinson syndrome, Hallermann-Streiff syndrome, Treacher-Collin syndrome, burns, trauma, postradiation therapy for facial cancer, surgically induced after treatment for cleft lip and palate, facial tumor or facial trauma, and trismus) cannot be extrapolated to patients in which restricted mouth opening is due to temporary or acute conditions (fascial muscle pain, trauma, tooth decay/dental pain, mumps, oral space infections, and trismus/temporomandibular dysfunction syndrome).

Nerve blocks and analgesics have been used to relieve acute trismus in various settings. Kojima et al.5 successfully used ultrasound-guided inferior alveolar nerve block to subside pain due to mouth opening during dental procedure and to improve mouth opening 20-40 mm. According to them, the dental procedure was performed without difficulty and the patient could keep her mouth open throughout the treatment. Earlier mandibular nerve block had also been described to relieve acute facial muscle spasm. No case has been reported in literature wherein opioids have been used to relieve spasm to improve airway assessment. Here we were successful in securing the airway following IV administration of propofol and muscle relaxant vecuronium (0.1 mg/kg). There was no difficulty in mask ventilation or intubation.

There are no clear cut guidelines regarding application of difficult airway predictors in patient having painful mouth opening and in uncooperative pediatric patient. A supervised dose of analgesic/anxiolytic might be useful in such scenarios.

ORCID

Amarjeet Kumar https://orcid.org/0000-0002-4272-5750

Chandni Sinha https://orcid.org/0000-0002-4107-2671

Ajeet Kumar https://orcid.org/0000-0002-1464-6684

Poonam Kumari https://orcid.org/0000-0003-0118-2187

Kritika Singh https://orcid.org/0000-0001-6910-4631

Gayatri D Sagdeo https://orcid.org/0000-0002-4799-2727

REFERENCES

1. Cook TM, Woodall N, Frerk C. 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society: Major complications of airway management 2011. Available from http://rcoa.ac.uk/nap4

2. Apfelbaum JL Hagberg CA Caplan RA et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118(02):251-270. DOI: 10.1097/ALN.0b013e31827773b2

3. Kheterpal S Healy D Aziz MF et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a report from the multicenter perioperative outcomes group. Anesthesiology 2013;119(06):1360-1369. DOI: 10.1097/ALN.0000435832.39353.20

4. Roth D Pace NL Lee A et al. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst Rev 2018;5(05):CD008874. DOI: 10.1002/14651858.CD008874.pub2

5. Kojima Y Sendo R Ohno S et al. Ultrasound-guided inferior alveolar nerve block for trismus during dental treatment: a case report. JA Clin Rep 2020;6(01):94. DOI: 10.1186/s40981-020-00400-0

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