title: Submucous fibrosis secondary to chewing of quids: another cause of unanticipated difficult intubation.
abstract: OBJECTIVE
  To report a case of unusual difficult intubation secondary to oral submucosal fibrosis (SMF) associated with malignancy of the hypopharynx.
  
  
  METHODS
  A 57-yr-old male, ASA-I physical status presented for percutaneous nephrolithotripsy. The patient was a known alcoholic and smoker with a habit of chewing quids for the past 36 years. Airway assessment revealed oral SMF and slight difficulty in opening the mouth fully. Mentohyoid and mentothyroid distances were normal. However, during intubation, unanticipated difficulty was encountered. On direct laryngoscopy, the tip of the epiglottis could barely be visualized. Intubation was possible after passing a gum elastic bougie blindly under the epiglottis and negotiating a 7.0 internal diameter tracheal tube over it. Postoperatively, indirect laryngoscopy (IDL) showed severe SMF involving the oral cavity, epiglottis and pyriform fossae and an ulcerative malignancy of the hypopharynx with fixation of the left hemilarynx.
  
  
  CONCLUSIONS
  SMF is a premalignant condition of the oral cavity associated with fibrosis of involved structures that can be associated with malignancy of the aerodigestive tract. Distortion of the airway anatomy may render intubation difficult. IDL maybe useful in the preoperative evaluation of these patients.
authors.affiliation: Department of Anaesthesia and Intensive Care Unit, Postgraduate Institute of Medical Education and Research (PGIMER ), Chandigarh, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Mahajan
authors.forename: Kajal
authors.initials: K
authors.lastname: Jain
authors.forename: Y K
authors.initials: YK
authors.lastname: Batra
mesh_terms: D001114:Areca; D005355:Fibrosis; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D008297:Male; D008409:Mastication; D008875:Middle Aged; D009061:Mouth Mucosa / Q000473:pathology*