What Is a Critical Mouth Opening for Macintosh Videolaryngoscopy? Results From a Prospective Observational Study.

Background and Aim: Video-laryngoscopes are commonly used for intubation in patients with restricted mouth openings. However, the predictors of difficult video-laryngoscope-guided intubation have not been clearly defined in the literature. The primary objective of this study was to identify the parameters that predict first-pass success with video-laryngoscope-guided nasal intubation in patients with oral cavity tumours and restricted mouth openings. The secondary objective was to determine the minimum mouth opening above which successful first-attempt intubation with a video-laryngoscope was achieved in this population. Methodology: After Institutional Review Board approval, a single-centre prospective observational study on 30 oral cavity tumour patients with mouth openings <5 cm was conducted. Both conventional and ultrasound-guided airway parameters – intercondylar distance (ICD), tongue thickness, skin to hyoid distance (DSH), skin to epiglottis distance (DSE) and hyomental distance ratio (HMDR) – were measured after screening. Patients were intubated with C-MAC D-Blade video-laryngoscopy. Successful safe video-laryngoscopy intubation is defined as first-attempt intubation, intubation time <60 s, without using any adjuncts and no adverse events. Results: The incidence of safe single-pass intubation was 12.79%, and the incidence of difficult laryngoscopy requiring more than 1 attempt was 17.2%. The mean interincisor distance, which was intubated within 60 s, was 2.97 ± 0.61 cm. Amongst the ultrasound parameters, HMDR was significantly different ( P = 0.05) in two groups requiring more than one attempt at intubation. ICD has a positive correlation with interincisor distance (IID). Conclusion: In patients with oral cavity tumours, restricted mouth opening, HMDR and ICD are the reliable predictors of difficult intubation with a video-laryngoscope. IID of 2.97 ± 0.61 cm was safely intubated within 60 s.

Airway management of an ankylosing spondylitis patient with severe temporomandibular joint ankylosis and impossible mouth opening

This study aims to investigate the correlations between clinical features and mouth opening in patients with systemic sclerosis (SSc). Eighty patients with SSc (13 males, 67 females; mean age 53.39±11.65 years; range, 31 to 76 years) followed in our clinic were enrolled in the study. Skin involvement was assessed using the modified Rodnan skin score (mRSS), joint/tendon involvement with finger-tip to palm (FTP) distance and interstitial lung disease (ILD) was evaluated with clinical and radiologic methods. The interincisal distance (ID) measurement was used to assess the maximal mouth opening capacity. We examined associations between the ID and clinical features of SSc. The ID was lower in females compared with males, and in diffuse type compared with the limited type (p<0.001 and p<0.001, respectively). A significant negative correlation was found between the ID with mRSS and FTP distance (p<0.001 and p=0.001, respectively). The ID was lower in patients with ILD than in patients without ILD (p=0.006). A formula was constituted to predict the maximal mouth opening of the patient with regression analysis. According to the formula, being male was associated with an increase of 6.14 mm, the presence of ILD with a decrease of 3.19 mm, every 10 mm increment in mRSS with a decrease of 3.72 mm and FTP distance >0 mm with a decrease of 5.13 mm in mouth opening. Microstomia is associated with low quality of life in patients with SSc. In our study, sex, ILD, mRSS, and FTP distance were observed to be the most important factors that were related with mouth opening in patients with SSc.

Accuracy of upper lip bite test (ULBT) has been compared with the Mallampati classification. In this study, we investigated whether the combination of the ULBT classification with sternomental distance (SMD), thyromental distance (TMD), and interincisor distance (IID) or a composite score can improve the ability to predict easy laryngoscopy and intubation compared with each test alone. In a prospective study, 380 patients who were scheduled for elective surgery were selected randomly and enrolled in the study. Before inducing anesthesia, the airways were assessed, and ULBT class, SMD, TMD, and IID determined. Laryngoscopic view according to the Cormack and Lehane grading system was determined after induction of anesthesia and Grades 3 and 4 defined as "difficult intubation." By using receiver operating characteristic analysis, the best cutoff points of the tests were calculated. Finally, sensitivity, specificity, positive and negative predictive values and accuracy of these tests and their combinations with the ULBT were calculated. The prevalence of difficult intubation was 5% (n = 19). Class III ULBT, IID <4.5 cm, TMD <6.5 cm, and SMD <13 cm were defined as predictors of difficult intubation. There was no significant difference regarding difficult intubation based on gender (P < 0.05), whereas there were significant differences between the older tests and laryngeal view (P < 0.05, Mc-Nemar test). Specificity and accuracy of the ULBT were significantly higher than TMD, SMD, and IID individually (specificity was 91.69%, 82.27%, 70.64%, and 82.27%, respectively, and accuracy was 91.05%, 71.32%, 81.84%, and 76.58%, respectively). The combination of the ULBT with SMD provided the highest sensitivity. We conclude that the specificity and accuracy of the ULBT is significantly higher than the other tests and is more accurate in airway assessment. However, the ULBT in conjunction with the other tests could more reliably predict easy laryngoscopy or intubation.

Surgical extraction of impacted mandibular third molars is one of the most common oral and maxillofacial procedures and is frequently associated with postoperative pain, swelling, and limitation of mouth opening. Pharmacological agents such as corticosteroids and proteolytic enzymes are widely prescribed to minimize these complications; however, comparative evidence on their efficacy remains limited. Objective: To compare the effectiveness of methylprednisolone and serratiopeptidase in reducing postoperative pain, swelling, and trismus following surgical extraction of impacted mandibular third molars. Methods: A randomized controlled trial was conducted at the Department of Oral and Maxillofacial Surgery, Sandeman Provincial Hospital, Quetta, Pakistan, from December 2021 to June 2022. Ninety-six eligible patients were randomly allocated into two equal groups. Group A received oral methylprednisolone 4 mg every 8 hours, and Group B received oral serratiopeptidase 10 mg every 12 hours for five days postoperatively. Pain was assessed using a visual analogue scale, swelling was measured using standardized anatomical landmarks, and mouth opening was recorded using interincisal distance. Data were analyzed using SPSS version 23, with p ≤ 0.05 considered statistically significant. Results: Both groups were comparable in age, gender distribution, impaction side, and impaction classification. Methylprednisolone demonstrated significantly lower postoperative pain (1.3 ± 0.32 vs 7.3 ± 2.0, p &lt; 0.001) and greater improvement in mouth opening (1.3 ± 2.5 vs 7.2 ± 4.1, p &lt; 0.001) than serratiopeptidase. Serratiopeptidase showed relatively better reduction in postoperative swelling (p = 0.04). Similar outcome trends were observed among participants aged 23–30 years. Conclusion: Methylprednisolone was more effective in reducing postoperative pain and trismus, whereas serratiopeptidase provided superior reduction in swelling following third molar surgery. The predominant clinical requirement may guide the selection of either medication. Both agents appear safe and beneficial when used short-term in postoperative management.

Background and Aim:Differences in patient characteristics due to race or ethnicity may influence the incidence of difficult airway. Our purpose was to determine the incidence of difficult laryngoscopy and intubation, as well as the anatomical features and clinical risk factors that influence them, in the Indian population.Methods:In 330 adult patients receiving general anaesthesia with tracheal intubation, airway characteristics and clinical factors were determined and their association with difficult laryngoscopy (Cormack and Lehane grade 3 and 4) was analysed. Intubation Difficulty Scale score was used to identify degree of difficult laryngoscopy.Results:The incidence of difficult laryngoscopy and intubation was 9.7% and 4.5%, respectively. Univariate analysis showed that increasing age and weight, male gender, modified Mallampati class (MMC) 3 and 4 in sitting and supine positions, inter-incisor distance (IID) ≤3.5 cm, thyromental (TMD) and sternomental distance, ratio of height and TMD, short neck, limited mandibular protrusion, decreased range of neck movement, history of snoring, receding mandible and cervical spondylosis were associated with difficult laryngoscopy. Multivariate analysis identified four variables that were independently associated with difficult laryngoscopy: MMC class 3 and 4, range of neck movement <80°, IID ≤ 3.5 cm and snoring.Conclusions:We found an incidence of 9.7% and 4.5% for difficult laryngoscopy and difficult intubation, respectively, in Indian patients with apparently normal airways. MMC class 3 and 4, range of neck movement <80°, IID ≤ 3.5 cm and snoring were independently related to difficult laryngoscopy. There was a high incidence (48.5%) of minor difficulty in intubation.

Compared with men, women often have a shorter interincisor distance and a shorter thyromental distance but are less likely to have difficult airway. The hypothesis is that the prediction criteria of difficult airway differ between men and women. The aim of this study was to investigate differences in the prediction criteria of anatomic predictors for difficult airways in men and women. We enrolled adult patients who underwent general anesthesia and tracheal intubation. The interincisor distance, thyromental distance, modified Mallampati test results, upper lip bite test results, and tongue thickness of each patient were evaluated prior to the initiation of anesthesia. The primary outcome was difficult tracheal intubation. Receiver operating characteristic (ROC) curve analysis and Youden's index were used to determine the criteria for predictors in men and women. In total, 1059 men and 1195 women were examined. Compared with women, men had a higher incidence of difficult tracheal intubation (P<0.001). The cut-off values for predicting difficult tracheal intubation of the interincisor distance, thyromental distance, modified Mallampati test results, upper lip bite test results, and tongue thickness determined by Youden's index were ≤38 mm, ≤70 mm, >3, >2, and >62 mm, respectively, for men, and ≤33 mm, ≤65 mm, >2, >1, and >60 mm, respectively, for women. The optimal cut-off values of predictors of difficult airway differ between males and females.

Physiotherapy Maneuver Is Critical to Recover Mouth Opening After Pediatric Trauma

The aim of this prospective study was to determine the reliability of temporomandibular joint (TMJ) mobility measurements for predicting difficult intubation. To evaluate the accuracy in predicting difficult intubation by TMJ mobility measurement, 762 patients requiring general anesthesia with tracheal intubation for elective surgery were enrolled in this prospective, observational, single-blind study. Maximum mouth opening, right-left jaw excursion, and degrees of protraction were determined with a digital inclinometer. Incisor gap was measured using a vernier caliper during full mouth opening. After induction of anesthesia using a standard protocol, the patient's grade of laryngeal view by Cormack-Lehane classification was documented by an anesthesiologist. We found that the degrees of protraction and incisor gap in the easy intubation group were significantly higher than those in the difficult intubation group. The incisor gap was found to be more sensitive (88.37%) and more specific (95.71%) than protraction degrees (58.14% and 59.76%, respectively). The results revealed that measurements of the incisor gap and degrees of protraction may be useful routine screening tests for preoperative prediction of difficult intubation.

THE Airtraq® (Prodol Meditec S.A., Vizcaya, Spain), a new disposable intubating device, was designed to provide a view of the glottis without alignment of the oral and pharyngeal axes. The Airtraq® laryngoscope (AL) has recently been used in patients with normal airways1and in simulated difficult airways,2but no study has assessed its performance in difficult airway patients. After training on a manikin, five senior staff anesthesiologists covering the obstetric anesthesia unit of our university hospital performed the clinical learning process with the AL. Because of its efficiency in the case of difficult tracheal intubation, the AL was incorporated into our emergency difficult airway management algorithm as a second-step airway device in the case of failed tracheal intubation using a standard Macintosh laryngoscope. We report two cases of emergency cesarean delivery parturients in whom the trachea was rapidly intubated using the AL after failed direct laryngoscopy. We discuss the place of the AL in a difficult airway management algorithm in parturients.Emergency cesarean delivery was decided during end-stage labor because of fetal acute cardiac rhythm abnormality (sustained fetal bradycardia) in one patient (aged 29 yr; body mass index, 38 kg/m2) and disproportion (aged 34 yr; body mass index, 44 kg/m2) for the second. Emergency induction of general anesthesia was the most realistic anesthesia technique for both informed patients, who had received oral ranitidine (400 mg) when they entered the labor room. The younger parturient, with a normal upper airway clinical evaluation (classified as Mallampati II; thyromental distance, 5.5 cm; interincisor distance, 4 cm), had firmly rejected epidural catheter placement for labor analgesia. Although we used a specifically designed needle set, spinal anesthesia attempts performed in the operating room failed for the other patient, who was classified as Mallampati III (IV in the operating room evaluation) with a 3.5-cm interincisor distance. With the surgeon installed and ready for operative delivery, the Sellick maneuver was applied in both women breathing 100% oxygen just before general anesthesia was induced with 3 mg/kg thiopental and 1 mg/kg succinylcholine. Direct laryngoscopy performed with a Macintosh metal blade showed Cormack grade 3 and 4, and tracheal insertion of a gum elastic bougie failed in both patients. Three minutes after loss of consciousness, the AL equipped with a video camera inserted into the pharynx provided an entire glottis view and video-endoscopy of the tube entering the trachea. The Sellick maneuver was maintained until capnography confirmed tracheal intubation. The times to optimal glottis view and to securing the airway (measured on video recording clips), defined as the time elapsing holding the AL to the best glottis exposition and inflation of the tube cuff, were of 10 and 14 s and 21 and 23 s, respectively. The lowest arterial oxygen saturations were 96% and 93%. Newborns of 3.7 and 5.5 kg had activity, pulse, grimace, appearance, and respiration scores of 9 and 10, respectively. The operating room tracheal extubation and postanesthesia care unit care of both parturients were unremarkable.We report two cases of rapid tracheal intubation with the AL after failed direct laryngoscopy in morbidly obese parturients undergoing emergency cesarean delivery.Maternal obesity is known to be associated with an increased risk of adverse pregnancy outcome, including an augmented emergency cesarean delivery rate.3However, the specific anesthesia-related risk associated with increased general anesthesia requirement rate in obese parturients is not discussed. Indeed, failures of neuraxial block placements were described in morbid obese parturients with a potential risk of difficult airway management. Levy4has recently proposed the safest and most effective approaches for the management of mother and baby in the emergency cesarean delivery situation. The author defined anesthetic options and recommended general anesthesia in the case of a true category 1 emergency (our first case) or if neuraxial regional analgesia has failed (our second case) but stated that the "traditional" rapid sequence induction (thiopental, succinylcholine, cricoid pressure, intubation) was probably not the safest approach to general anesthesia for cesarean delivery. If we all agree that unrecognized esophageal intubation is directly linked to the tracheal intubation technique, we believe that this dramatic complication cannot be attributed to rapid sequence induction, but rather to the inefficiency of the method used to intubate the trachea, i.e. , standard direct laryngoscopy, particularly in the difficult airways of parturients. Indeed, rapid sequence induction was recently demonstrated to reduce the incidence of difficult tracheal intubation and complications in emergency situations.4There are only two validated airway devices allowing visualization of the glottis without alignment of oral and pharyngeal axes: the LMACTrach (SEBAC, Pantin, France) and the AL. We have used the LMACTrach to intubate difficult airway patients in the operating room,5but the mean time to securing the airway was almost 3 min. On the other hand, we observed that the AL in association with rapid sequence induction resulted in a short delay (≤ 1 min in most cases) to secure the emergency difficult airways. Then, we selected a low threshold for using the AL in obstetric emergency anesthesia. We decided that after 2 min of failed tracheal intubation using direct laryngoscopy, rescue AL tracheal intubation should be attempted. After 6 months, this algorithm has been applied by the obstetric anesthesia team; 69 parturients underwent emergency cesarean delivery during general anesthesia, and 2 required the AL. We are now considering placing the AL as a primary airway management device in the case of emergency cesarean delivery in women showing predictive difficult airway factors at labor or operating room clinical evaluation.

Comparison of curcumin with intralesional steroid injections in Oral Submucous Fibrosis – A randomized, open-label interventional study

Preanesthetic assessment data do not influence the time for tracheal intubation with Airtraq™ video laryngoscope in obese patients

Retrograde intubation through nasal route in patients with limited mouth opening undergoing oral and maxillofacial surgery

Introduction This study aimed to determine the maximum mouth opening [MMO] among a group of Sudanese adults. Reduced mouth opening [MO] can lead to difficulties in mastication and social interactions, potentially impacting dental treatment planning. Comparing the MMO values between males and females, relating each subject’s 3-4 finger width to inter-incisal distance was the method used. Methodology A total of 277 undergraduate students [179 females and 98 males], aged 18–25 years, participated in the study. MMO was measured as the vertical inter-incisal distance using a digital vernier caliper. Participants were also assessed on the number of fingers they could fit vertically between their incisors, with the normal range defined as 3–4 fingers. The finger width in millimeters was then compared to the previously measured MMO. Additionally, the ratio between MMO and maximum lateral mandibular movements [right and left excursions] was recorded. Results The overall mean MMO was 52.64 ± 6.4 mm, with males exhibiting a significantly higher mean MMO [56.33 ± 6.77 mm] compared to females [50.62 ± 5.19 mm]. Approximately 69.3% [n=192] of participants could place four fingers vertically between their incisors. A statistically significant difference was found when comparing the mean MMO to the finger width measurements [p &lt; 0.001]. The mean lateral excursion was 9.13 mm, and a significant correlation between MMO and lateral excursion was observed, with a ratio of approximately 1:5.6 Discussion The mean MMO was 52.6 mm, higher than most previous studies, possibly due to ethnic and physical differences. Males showed greater MMO than females, likely due to larger mandibular size, although females may have relatively greater joint mobility. Most subjects could insert four fingers vertically between their incisors, unlike other populations, reflecting higher MMO in this group. Lateral mandibular movement averaged 9.13 mm, consistent with other studies, and a weak positive correlation was found between vertical and lateral mouth movements, especially in males. Conclusion The mean MMO in this Sudanese adult population was 52.64 mm, with males demonstrating significantly greater mouth opening than females. Most participants [69.3%] could accommodate four fingers inter-incisally. The ratio of MMO to lateral excursion was higher than previously reported in the literature, suggesting potential population-specific variations.

Spray and stretch technique and its effects on mouth opening