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Gum elastic bougie-guided insertion of the LMA-ProSeal^TM in occult tonsillar hypertrophy

¹ Cairns, Australia
² Innsbruck, Austria

To the Editor:

A 29-yr-old, 105-kg male ASA physical status I presented for an anterior cruciate ligament repair. Preoperative evaluation revealed a Mallampati grade 1 airway and the patient had no significant past medical history. After induction of anesthesia and easy face mask ventilation, a size 5 ProSeal^TM laryngeal mask airway (Laryngeal Mask Company, Henley-On-Thames, UK) was inserted using the digital technique; however, it was impossible to advance the cuff into the pharynx using either a midline or lateral approach. A laryngoscope was inserted to determine the cause of the obstruction and revealed bilateral hypertrophic tonsils, which almost kissed in the midline, and a trace of blood from a small mucosal tear on the soft palate. In addition, the hypopharynx but not the larynx could be seen. To bypass the obstruction, a gum elastic bougie, with its straight end first, was inserted under laryngoscope-guidance into the hypopharynx and advanced 5 cm into the esophagus.¹ The proximal end of the gum elastic bougie was fed into the drain tube of the LMA-ProSeal^TM, which was then railroaded between the tonsils with the cuff rotated laterally (so that it was aligned with the slit-like intertonsillar gap), and then rotated anteriorly as it entered the laryngopharynx (so that it was aligned with the glottis). The cuff was inflated with 20 mL of air and high tidal volumes were obtained. The procedure was otherwise uneventful and there were no problems during emergence or after removal of the LMA-ProSeal^TM. There was no postoperative pharyngolaryngeal discomfort.

The use of an instrument placed in the esophagus to facilitate correct positioning of an airway device is a counter-intuitive but important new concept. Other instruments that have been used as guides with the LMA-ProSeal^TM include a gastric tube² and a fibreoptic scope.³ In principle, these techniques are applicable to any extraglottic airway device with a drain tube that is intended to sit in the hypopharynx/esophagus.

References

1 Howarth A, Brimacombe J, Keller C. Gum-elastic bougie-guided insertion of the ProSeal^TM laryngeal mask airway: a new technique. Anaesth Intensive Care 2002; 30: 624–7.[Medline]

2 Drolet P, Girard M. An aid to correct positioning of the ProSeal laryngeal mask (Letter). Can J Anesth 2001; 48: 718–9.[Free Full Text]

3 Brimacombe J, Keller C. Awake fibreoptic-guided insertion of the ProSeal Laryngeal Mask Airway^TM (Letter). Anaesthesia 2002; 57: 719.

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