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Puncture of the laryngeal mask airway during stellate ganglion block

Sherbrooke, Québec

To the Editor:

Performing a stellate ganglion block (SGB) while a laryngeal mask airway (LMA) is in place may be hazardous. The tip of the LMA cuff lies within the esophagus, just above the cricoid cartilage.¹ During SGB, the needle is inserted just below the cricoid cartilage, beside the esophagus.^2,3

A 39-yr-old man came to the operating room for a change of dressing over his right hand. A SGB was required to relieve pain and help healing of the hand. Under general anesthesia, a #5 LMA was inserted easily. A right SGB was then performed using a #21 needle. The right carotid was retracted laterally, and the neck extended. While slowly advancing the needle perpendicularly at the medial edge of the sternocleidomastoid muscle, just below the lower edge of the cricoid cartilage, continuous aspiration through the syringe was applied. The syringe became filled with a few millilitres of air. The needle was advanced a little further and contacted Chassaignac's tubercle. The needle was withdrawn approximately 2 mm. Aspiration for blood or cerebrospinal fluid was negative while 10 mL of local anesthetic was injected gradually. Throughout the surgical procedure, the patient's ventilation was easy and no air leak was audible. At the post-anesthesia care unit, the patient was calm, had right ptosis and a sensation of warmth in his right upper extremity. After removal, the LMA was filled with saline, revealing two holes at its tip (Figure). No postoperative infectious morbidity resulted from this accidental puncture of the LMA.

References

1 Brimacombe JR, Berry AM, Brain AIJ. The laryngeal mask airway. Anesthesiol Clin North Amer 1995; 13: 411–37.

2 Breivik H, Cousins MJ, Löfström JB. Sympathetic neural blockade of upper and lower extremity. In: Cousins MJ, Bridengaugh PO (Eds). Neural Blockade in Clinical Anesthesia and Management of Pain, 3rd ed. Philadelphia: Lippincott-Raven Publishers, 1998: 411–45.

3 Morgan GE Jr, Mikhail MS. Clinical Anesthesiology, 2nd ed. Stamford: Appleton & Lange, 1996.

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