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REPLY

Tan Tock Seng Hospital, Singapore, Republic of Singapore, E-mail: gasgenie{at}yahoo.co.uk

We sincerely thank Stix and colleagues for their valuable comments and interesting figures. They have clearly shown that the Proseal^TM laryngeal mask airway (PLMA; Laryngeal Mask Company, Henley-on-Thames, UK) has a tendency to exert pressure on, and cause mechanical distortion of the larynx, a fact that we alluded to in our discussion.

We agree that the appearance of the aryepiglottic folds in our figure is somewhat similar to that shown by Stix and colleagues, and that it may be difficult to ascertain if there is significant edema of these structures. We disagree, however, that mechanical obstruction was the primary cause of the observed clinical phenomena. The most striking feature in our case was edema of the true vocal cords. This may be appreciated from their abnormal bulbous appearance, and the manner in which they stand out in relief against the surrounding mucosa (Figure). The rima glottidis was consequently narrowed to two pinhole-sized openings, which accounts for the clinical finding of high-pitched wheeze. Previous reports of mechanical obstruction do not describe wheeze or stridor as a clinical feature.^1,2 The delayed onset of wheeze and increased airway resistance, as well as clinical resolution following the administration of iv dexamethasone, is also inconsistent with mechanical obstruction as the primary cause. Finally, recommended measures to relieve mechanical obstruction include cuff deflation and repositioning of the head and neck in the sniffing position,¹ none of which was attempted in our patient.

View larger version (183K): [in this window] [in a new window]   FIGURE Fibreoptic bronchoscopic view of the lar yngeal inlet. The true vocal cords have an abnormally swollen, bulbous appearance, and the rima glottidis has been narrowed to two pinhole-sized openings (labelled arrows). There is also localized swelling of the left ar yepiglottic fold (unlabelled arrow).

References

1 Brimacombe J, Richardson C, Keller C, Donald S. Mechanical closure of the vocal cords with the laryngeal mask airway ProSeal. Br J Anaesth 2002; 88: 296–7.[Abstract/Free Full Text]

2 Stix MS, O’Connor CJ Jr. Maximum minute ventilation test for the ProSeal laryngeal mask airway. Anesth Analg 2002; 95: 1782–7.[Abstract/Free Full Text]

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This Article Full Text (PDF) Submit a scholarly reply Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Related articles in CJA Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Chin, K. J. Articles by Chee, V. W.T. Search for Related Content PubMed Articles by Chin, K. J. Articles by Chee, V. W.T.