Use of a Macintosh blade in extrahepatic portal vein obstruction with difficult intubation: two case reports.
BACKGROUND
We report the management of two patents from the Indian subcontinent with extrahepatic portal vein obstruction presenting with anticipated difficult airway. A Macintosh blade was used to secure the airway after using various instruments designed for difficult airway. To the best of our knowledge, no case has previously been reported in which a Macintosh blade was used successfully in patients with extrahepatic portal vein obstruction with a difficult airway.


METHODS
Two women (case 1 and case 2) of South Asian ethnicity with extrahepatic portal vein obstruction presented for an elective splenorenal shunt. They both had micrognathia and restricted mouth openings. They had similar airway profiles with mouth openings of just 2 cm, Mallampati class IV, a thyromental distance <4 cm, a hyomental distance <2.5 cm, and a sternomental distance of 10 cm. Awake intubation was attempted in both patients after standard airway preparation in the form of preoperative 4 % lignocaine nebulization and 2 % viscous lignocaine gargle along with an on-table supralaryngeal nerve block using 2 % lignocaine and transtracheal infiltration with 4 % lignocaine. The patient in case 1 tolerated the procedure well whereas the patient in case 2 had to be given propofol 60 mg. Endotracheal intubation with a 6.5 mm polyvinyl chloride endotracheal tube was attempted using a Truview EVO2, an Airtraq, and a Miller blade no. 3 but was unsuccessful. Finally, a trial intubation was performed successfully with a Macintosh blade with a stubby handle assisted by a Frova Intubating Introducer in case 1 and a gum elastic bougie in case 2.


CONCLUSIONS
Although many instruments have been introduced to manage difficult airways, our experience in these cases suggests that the Macintosh blade can be used first when attempting endotracheal intubation before using other instruments. Patients from the Indian subcontinent with extrahepatic portal vein obstruction are often found to have associated temporomandibular joint ankyloses (hence difficult airways). We hypothesize that a difficult intubation should be anticipated in these patients. Such an association has not been made before.
Department of Anaesthesiology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, 400012, India. kuzhonulu@gmail.com.|, House no 21, Near Green Park, Sixth Mile, Dimapur, Nagaland, 782062, India. kuzhonulu@gmail.com.
Azho
http://orcid.org/0000-0002-7051-4205
A
Kezo
Department of Anaesthesiology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, 400012, India.
Rajendra D
RD
Patel
Department of Anaesthesiology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, 400012, India.
Shraddha
S
Mathkar
Department of Anaesthesiology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Dr. E. Borges Road, Parel, Mumbai, Maharashtra, 400012, India.
Sonal
S
Butada
D000293:Adolescent; D000844:Ankylosis / Q000150:complications*; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000601:surgery*; D004867:Equipment Design; D005260:Female; D006801:Humans; D007194:India; D007442:Intubation, Intratracheal / Q000295:instrumentation* / Q000379:methods; D011169:Portal Vein / Q000000981:diagnostic imaging / Q000473:pathology*; D013705:Temporomandibular Joint Disorders / Q000150:complications*; D016896:Treatment Outcome
Airtraq; Case report; Difficult airway; Extrahepatic portal vein obstruction (EHPVO); Indian subcontinent; Macintosh; Miller; South Asian ethnicity; Temporomandibular joint (TMJ) ankyloses; Truview EVO2