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Canadian Journal of Anesthesia 48:513 (2001)
© Canadian Anesthesiologists' Society, 2001

Correspondence

The "toothpaste method" for anesthesia of the difficult airway

Ruchi Gupta, MD DNBE, Savita Saini, MD and Kiran Preet, DA

Harayana, India

To the Editor:

Recently, Drummond described a variation of the method reported by Chung et al. for achieving topical anesthesia of the airway.1,2 Using this technique we were able to handle a difficult airway in an emergency situation.

A 60-yr-old female, presented with massive swelling of the neck secondary to carcinoma of the thyroid. On examination the patient had dyspnea, tachypnea, inspiratory stridor and was unable to remain supine. The trachea and lower portion of the thyroid could not be palpated. Respiratory acidosis was present and, with oxygen supplementation, SpO2 was maintained between 97–99%. An emergency tracheostomy under local anesthesia in a semi-reclined position was planned.

Because of the distorted anatomy, the surgeons requested the trachea be intubated to allow its localization. In view of the compromised airway, the "toothpaste method" was used to anesthetize the upper airway. The patient was asked to protrude the tongue and lidocaine 2% jelly was applied at the back of the tongue with the instruction to not swallow it. After approximately ten minutes, anesthesia of the base of the tongue allowed laryngoscopy. On visualization, the jelly was seen trickling down the larynx. The trachea was intubated with a 5-mm cuffed endotracheal tube without any cough response. We speculate that aspiration of lidocaine jelly occurred by way of two mechanisms. First, by refraining the patient from swallowing and, second, the rapid respiratory rate guided the jelly towards the trachea. The rest of the surgical procedure and postoperative recovery were uneventful.

We conclude that anesthesia of the airway by aspiration of lidocaine is an interesting alternative in difficult situations where local blocks are not feasible.

References

1 Drummond JC. Airway anesthesia: the toothpaste method. Can J Anesth 2000; 47: 94.[Free Full Text]

2 Chung DC, Mainland P-A, Kong AS. Anesthesia of the airway by aspiration of lidocaine. Can J Anesth 1999; 46: 216–9.





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