Pharyngolaryngeal morbidity with the laryngeal mask airway in spontaneously breathing patients: does size matter?

Intravenous fentanyl vs. topical lignocaine for ProSeal™ laryngeal mask airway insertion with propofol induction

Insertion of the laryngeal mask airway (LMA) without muscle relaxant requires adequate obtundation of airway reflexes, which may otherwise lead to incorrect or failed LMA placement. This study compared topical lignocaine spray vs. intravenous (IV) fentanyl, during propofol induction for insertion of the ProSeal™ LMA (PLMA). This was a prospective, randomized, double blind study, in ASA I or II patients, for elective or emergency surgery. Seventy patients (n = 70) who fulfilled the inclusion criteria were randomly assigned to receive IV fentanyl 2 mcg/kg or topical lignocaine spray 40 mg, prior to anesthesia induction with IV propofol (2–2.5 mg/kg). ProSeal™ LMA insertion condition was regarded optimal in the absence of adverse responses (gag, cough, laryngospasm and body movements), and successful LMA placement at the first attempt. Hemodynamic parameters were recorded and patients were assessed for sore throat and hoarseness post operatively. Seventy patients were analyzed. The number of patients with optimal PLMA insertion conditions were comparable between the groups (60% vs. 57%, P = 0.808). All hemodynamic parameters were comparable between groups with the exception of heart rate. Sympathetic obtundation of heart rate was greater with IV fentanyl than topical lignocaine (P < 0.05). The proportion of patients with postoperative sore throat significantly increased with the number of insertion attempts (P < 0.05). Topical lignocaine spray to the pharynx is as effective, and may be an alternative to IV fentanyl, during propofol induction for PLMA insertion. Success rate and optimal insertion condition at the first attempt, propofol requirement, blood pressure, adverse events and airway complications were comparable. Heart rate obtundation was less with topical lignocaine spray but remained within clinically acceptable values.

Pharyngolaryngeal Morbidity With the Laryngeal Mask Airway SupremeTM at Different Fiberoptic Bronchoscopy Grades: An Observational Study

OBJECTIVE

To assess whether the different fiberoptic bronchoscopy (FOB) grades of laryngeal mask airway (LMA) Supreme™ affects pharyngolaryngeal morbidity (PLM, including sore throat, dysphonia, pharyngoxerosis, and dysphagia) after general anesthesia.

METHODS

A total of 235 adult patients scheduled for elective laser lithotripsy undergoing general anesthesia with the placement of LMA Supreme™ were enrolled. The position of LMA Supreme™ was assessed by FOB and categorized into five grades. Meanwhile, patients were divided into four groups (grades A-D); none was assessed as grade E. We collected blinded data on PLM at 2 (H+2), 6 (H+6), and 24 hours (H+24) postoperatively. The incidence and severity of PLM as the primary outcome and incidence of PLM at three time points as a secondary outcome were compared.

RESULTS

The incidence of PLM was higher at 2 and 6 hours than at 24 hours; however, no significant difference was found between the incidence of PLM in the FOB groups. Furthermore, the severity of sore throat and dysphonia between groups were obviously differed at H+6 and H+24, but similar at H+2. The severity of postoperative pharyngoxerosis and dysphagia were similar between groups at three time points.

CONCLUSIONS

A positive association was found between the severity of postoperative sore throat and dysphonia and FOB grade after LMA Supreme™ placement. PLM secondary to placement of the LMA Supreme™ was short lasting.

A prospective study on the incidence of sore throat after use of laryngeal mask airway during general anesthesia

Background

Laryngeal mask airway (LMA) is a useful alternative to intubation of the trachea to maintain the airways. The aim of this study was to evaluate the incidence of sore throat after LMA during general anesthesia in short-duration elective surgery.

Method

In this prospective study, 76 patients undergoing surgery with general anesthesia in (XXX) during 2018 and 2019 were selected and their demographic information were entered into the data collection form. Laryngeal mask airway was used in the subjects for airway maintenance during the surgery. The incidence of sore throat at postoperative 0, 6, 12 h was measured using Visual Analogues Scale (VAS) as primary outcome and it was then compared with demographic parameters as secondary outcomes.

Result

The mean age of the patient was 45.48 ± 14.89 years and 46 (60.5 %) of the patients were women. The mean BMI was 24.02 ± 3.05 kg/m². The average duration of surgery was 56.9 ± 15.9 min. The incidence of sore throat immediately after the surgery and at 6 and 12 postoperative hours was 26.3 %, 23.7 %, and 19.7 %, respectively. The incidence of sore throat after the use of LMA was not significantly correlated with age, sex, and BMI (P > 0.05)

Conclusions

The findings of our study showed that pain due to sore throat following laryngeal mask airway was reported to be mild in our study. The postoperative sore throat may not associated with demographic variables.

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Laryngeal mask airway is a useful alternative to intubation of the trachea to maintain the airways.

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Tracheal intubation is one of the invasive procedures used in patients undergoing surgery.

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The pain due to sore throat was reported to be mild in our study.

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Postoperative sore throat was not associated with demographic variables.

Life threatening abscess in the visceral space with penicillin and metronidazole resistant Prevotella Denticola following use of a laryngeal mask airway: case report

Background

Laryngeal mask airways (LMA) are commonly used for airway management. Complications with this device are rare. However, when they do occur, there is a high risk for respiratory problems, necessitating early diagnosis and treatment. We present the first case of a life-threatening abscess spreading in the visceral space caused by a penicillin and metronidazole resistant Prevotella Denticola after the use of an LMA.

Case presentation

A female patient was admitted to our day care centre for bunion surgery. A single use LMA size 3 (Solus®, intersurgical, Wokingham, Berkshire, United Kingdom) was successfully inserted. After surgery, the patient complained of a sore throat and amoxicillin was prescribed by the general practitioner. Three days after surgery the patient was admitted to the Intensive Care Unit (ICU) for obstructive breathing, due to an abscess in the visceral space. Retropharyngeal and certainly parapharyngeal abscesses in adults are already rare. This case however, is unique because it is the first case of abscess spreading into the visceral space after the use of an LMA. Amoxicillin/clavulanate and vancomycin were started. The abscess was incised 5 days later and microbiology showed 3 positive cultures of the anaerobe Prevotella denticola, resistant for penicillin and metronidazole, but sensitive for amoxicillin/clavulanate. The patient fully recovered.

Conclusion

LMA’s are easy to use and are established, safe tools to support ventilation of the airway. In this case, the authors hypothesise a small wound in the lateral pharyngeal wall probably created an opening into the visceral space causing infection with Prevotella denticola, supporting the idea that the pharyngeal mucosal space must be part of the visceral space. Additionally, early recognition and treatment of an LMA induced abscess is necessary to prevent evolution of complications leading to airway obstruction.

Comparison of Intracuff Pressure and Postoperative Sore Throat Following Use of Laryngeal Mask Airway Protector With or Without Nitrous Oxide Anesthesia

PURPOSE

In general anesthesia, the laryngeal mask airway (LMA) is a frequently used effective option. The effect of nitrous oxide on intracuff pressure of the LMA and postoperative sore throat is well known; however, there are no studies related to the second-generation LMA Protector. The purpose of this study was to determine the differences in intracuff pressure and postoperative sore throat, depending on the use of nitrous oxide during general anesthesia using the LMA Protector.

DESIGN

This randomized double-blind prospective study was conducted among 88 patients aged 20 to 70 years.

METHODS

The cuff pressure started with a baseline of 40 cm H₂O and was measured using a digital cuff pressure manometer for 30 minutes. Postoperative sore throat, dysphonia, dysphagia, and numeric rating scale scores were also recorded.

FINDINGS

Over time, the intracuff pressure of the nitrous oxide group increased significantly compared with that of the air group. Furthermore, postoperative sore throat and pharyngolaryngeal complications were not significantly different between the two groups.

CONCLUSIONS

Intracuff pressure of the LMA Protector increased during anesthesia using nitrous oxide. When the anesthesia time was less than 2 hours, however, there was no difference in postoperative sore throat.

[Comparison of two supraglottic airway devices on postoperative sore throat in children: a prospective randomized controlled trial]

BACKGROUND AND OBJECTIVE

Sore throat is well recognized complaint after receiving general anesthesia. This study is conducted to compare the severity and frequency of postoperative sore throat in children undergoing elective surgery - following the use of Ambu laryngeal mask airway) or I-gel® - who are able to self-report postoperative sore throat.

METHOD

Seventy children, 6 to 16 years-old, undergoing elective surgery randomly allocated to either Ambu laryngeal mask (Ambu Group) or I-gel® (I-gel Group). After the procedure, patients were interviewed in the recovery room immediately, after one hour, 6 and 24 hours postoperatively by an independent observer blinded to the device used intra-operatively.

RESULTS

On arrival in the recovery room 17.1% (n=6) of children of the Ambu Group complained of postoperative sore throat, against 5.7% in I-gel Group (n=2). After one hour, the results were similar. After 6 hours, postoperative sore throat was found in 8.6% (n=3) of the children in Ambu group vs. 2.9% (n=1) in I-gel Group. After 24hours, 2.9% (n=1) of the kids in Ambu Group compared to none in I-gel Group. There was no significant difference found in the incidence of postoperative sore throat in both devices on arrival (p=0.28); after 1 hour (p=0.28); after 6 hours (p=0.30); and after 24 hours (p=0.31). The duration of the insertion was shorter in Ambu Group and it was easier to insert the I-gel® (p=0.029). Oropharyngeal seal pressure of I-gel® was higher than that of Ambu laryngeal mask (p=0.001).

CONCLUSION

The severity and frequency of postoperative sore throat in children is not statistically significant in the I-gel Group compared to Ambu Group.

Comparison of two supraglottic airway devices on postoperative sore throat in children: a prospective randomized controlled trial

Background and objective

Sore throat is well recognized complaint after receiving general anesthesia. This study is conducted to compare the severity and frequency of postoperative sore throat in children undergoing elective surgery, following the use of Ambu laryngeal mask airway or I-gel®, who are able to self-report postoperative sore throat.

Method

Seventy children, 6 to 16 years-old, undergoing elective surgery randomly allocated to either Ambu laryngeal mask (Ambu Group) or I-gel® (I-gel Group). After the procedure, patients were interviewed in the recovery room immediately, after one hour, 6 and 24 hours postoperatively by an independent observer blinded to the device used intra-operatively.

Results

On arrival in the recovery room 17.1% (n = 6) of children of the Ambu Group complained of postoperative sore throat, against 5.7% in I-gel Group (n = 2). After one hour, the results were similar. After 6 hours, postoperative sore throat was found in 8.6% (n = 3) of the children in Ambu group vs. 2.9% (n = 1) in I-gel Group. After 24 hours, 2.9% (n = 1) of the children in Ambu Group complained of postoperative sore throat compared to none in I-gel Group. There was no significant difference found in the incidence of postoperative sore throat in both devices on arrival (p =  0.28); after 1 hour (p =  0.28); after 6 hours (p =  0.30); and after 24 hours (p =  0.31). The duration of the insertion of Ambu laryngeal mask was shorter and it was easier to insert than I-gel® (p =  0.029). Oropharyngeal seal pressure of I-gel® was higher than that of Ambu laryngeal mask (p =  0.001).

Conclusion

The severity and frequency of postoperative sore throat in children is not statistically significant in the I-gel Group compared to Ambu Group.

Detrimental Effects of Filling Laryngotracheal Airways To Excessive Pressure (DEFLATE-P): a quality improvement initiative

Background

This quality improvement (QI) project was performed at a single center to determine the incidence of postoperative complications associated with use of cuffed airway devices. An educational program was then completed that involved training our anesthesia providers about complications related to excessive cuff pressure and how to utilize a quantitative cuff pressure measurement device (manometer). The impact of this educational initiative was assessed by comparing the incidence of postoperative complications associated with the use of airway devices before and after the training period.

Methods

After approval by our institution’s Institutional Review Board, a pre-intervention (baseline) survey was obtained from 259 adult patients after having undergone surgery with general anesthesia with the use of an endotracheal tube (ETT) or laryngeal mask airway (LMA). Survey responses were used to determine the baseline incidence of sore throat, hoarseness, and dysphagia. Once these results were obtained, education was provided to the anesthesia department members addressing the complications associated with excessive cuff pressures, appropriate cuff pressures based on manufacturer recommendations, and instructions on the use of a quantitative monitor to determine cuff pressure (manometry). Clinical care was then changed by requiring intraoperative cuff pressure monitoring throughout our institution for all surgical patients. After this educational period, 299 patients completed the same survey describing postoperative airway complications.

Results

The use of manometry reduced the incidence of moderate-to-severe postoperative sore throat in the pre- vs. post-intervention groups (35 patients vs 31 patients, p = 0.045), moderate to severe hoarseness (30 patients vs 13, patients p = 0.0001), and moderate-to-severe dysphagia (13 patients vs 5 patients, p = 0.03).

Conclusion

Caring for patients in the perioperative setting frequently entails placement of an airway device. This procedure is associated with several potential complications, including sore throat, coughing, and vocal cord damage. Our quality improvement initiative has shown that intraoperative management of intra-cuff pressure based on manometry is feasible to implement in clinical practice and can reduce postoperative airway complications.

Unilateral hypoglossal nerve palsy after the use of laryngeal mask airway (LMA) Protector

BACKGROUND

The laryngeal mask airway (LMAⓇ) ProtectorTM (Teleflex Medical Co., Ireland) is the latest innovation in the second generation of LMA devices. One distinguishing feature of this device is its integrated, color-coded cuff pressure indicator (Cuff PilotTM technology) which enables continuous cuff pressure monitoring and allows adjustments when necessary; this ensures patient safety due to better monitoring.

CASE

We report a case of postoperative unilateral hypoglossal nerve palsy after uncomplicated use of the LMA Protector. To the best of our knowledge, this could be the second reported case.

CONCLUSIONS

This case demonstrates that anesthetists need to routinely measure cuff pressure and that the Cuff PilotTM technology is not a panacea for potential cranial nerve injury after airway manipulation.

Comparing the insertion and ventilation of laryngeal mask airway according to the patient's head position and muscle relaxation use. A prospective clinical trial

OBJECTIVES

To assess the insertion and ventilation of the laryngeal mask airway (LMA) classic while using different head positions with or without muscle relaxant.

METHODS

This is a double-blind randomized clinical trial. Patients scheduled for ureteral calculus surgery at Shanghai General Hospital, Shanghai, China were recruited between November 2017 and November 2018. A total of 132 adults were consecutively selected. Patients were randomly divided into 4 groups according to head positioning and muscle relaxant use. An 8-cm-high pillow was used to achieve the sniffing position. The insertion time, initial peak pressure (Ppeak), mean pressure (Pmean) of the airway during intermittent positive pressure ventilation (primary endpoint) and fiberoptic score of the LMA position (secondary endpoint) were evaluated via electronic bronchoscopy through the mask bar. All adverse events were recorded. Results: Data were analyzed by ANOVA, 2-way ANOVA, Chi-squared, Cochran-Mantel-Haenszel, and Kruskal-Wallis tests. The insertion time required for the first attempt, fiberoptic score, Ppeak and Pmean did not differ among the groups. However, the incidence of adverse events in groups not using muscle relaxant was higher than in those using muscle relaxant. Conclusion: Use of a sniffing position and muscle relaxant slightly eased the insertion of the LMA but did not affect the fiberoptic score or ventilation parameters. Using a muscle relaxant, but not the sniffing position, reduced the incidence of adverse effects.

Comparison of standard versus 90° rotation technique for LMA Flexible™ insertion: a randomized controlled trial

Background

Insertion of a flexible laryngeal mask airway (LMA Flexible) is known to be more difficult than that of a conventional laryngeal mask airway. The 90° rotation technique can improve the success rate with a conventional laryngeal mask airway but its effect with the LMA Flexible remains unknown. We assessed whether the 90° rotation technique increased the first-attempt success rate of LMA Flexible insertion versus the standard technique.

Methods

In total, 129 female patients undergoing breast surgery were analyzed. The primary endpoint was success at the first attempt. The insertion time, number of trials, number of manipulations required, and oropharyngeal leak pressure were also evaluated. Heart rate and mean blood pressure were recorded 1 min before and 1 min after insertion. Blood staining on the LMA Flexible after removal and postoperative sore throat were checked.

Results

The first-attempt success rates were comparable between the groups (93% vs. 98.3%, P = .20). The insertion time, number of trials and manipulations, hemodynamic variables, and complications, such as blood staining and sore throat, did not differ between the groups.

Conclusions

The 90° rotation technique is a good alternative to the standard technique for insertion of the LMA Flexible.

Trial registration

ClinicalTrials.gov (NCT03028896). It was registered retrospectively at Jan 19th, 2017.

Randomized Evaluation of the Single-use SoftSeal™ and the Re-useable LMA Classic™ Laryngeal Mask

A number of laryngeal masks are available, including both re-usable and single-use masks. Single-use laryngeal masks may decrease the risk of transmitting prion infections. We performed a single-blind randomized trial in 200 spontaneously breathing female patients under general anaesthesia with nitrous oxide, to compare a new single-use laryngeal mask, the SoftSeal™ (Portex Ltd, U.K.), with a re-usable laryngeal mask, the LMA Classic™ (Laryngeal Mask Company Ltd., Cyprus). The primary outcome was successful insertion at the first attempt. Size 4 single-use (n=99) or re-usable (n=100) laryngeal masks, inserted by experienced anaesthetists, were equivalent for successful placement at the first attempt (90% versus 91% respectively). The single-use mask was less easy to insert (47% difficult versus 9%, P<0.001). Clinical and anatomical tests of position and function were similar. The cuff pressure of the re-usable mask increased significantly compared with the single-use mask (median +10 cm versus –2 cm H 2 O, P<0.001). Forty per cent of patients allocated the single-use mask and 20% of those allocated the re-usable mask experienced sore throat at 24 hours postoperatively (P<0.05). An estimation of cost per patient use was greater for the re-usable mask.

We conclude that the SoftSeal™ single-use laryngeal mask and the LMA Classic™ re-usable laryngeal mask airway are of similar clinical utility in terms of successful insertion and airway maintenance. The re-usable laryngeal mask was easier to insert and associated with less postoperative sore throat, but costs were higher.

Evaluation of the SLIPA™ (Streamlined Liner of the Pharynx Airway), a Single Use Supraglottic Airway Device, in 60 Anaesthetized Patients Undergoing Minor Surgical Procedures

The Streamlined Liner of the Pharyngeal Airway, SLIPA™ (Hudson RCI) is a new disposable supraglottic airway device that has no inflatable cuff and has features designed to reduce aspiration risk. This study aimed to assess the insertion success and effectiveness of the SLIPA™ in 60 patients who presented for elective surgery. Ethics committee approval was obtained. Patients were excluded if they were less than 18 years, had not provided written consent or were at risk of pulmonary aspiration. The first 20 SLIPA™ were inserted by the principal investigator (Group A) followed by another 40 inserted by medical officers and anaesthetists of varying experience (Group B). Twenty-one males and 39 females were recruited into the study. Median time to ventilation was 20.4 seconds in Group A (range 12.9-109) and 24.8 seconds in Group B (range 8.2-82.5). Overall success rate was 100% in Group A and 92.5% in Group B. The lowest recorded SpO2 was 91% in Group B. The incidence of blood and sore throat score >3 (0-10 scale) was 23% and 7% respectively (Groups A and B). Group B reported that use of the device was very easy in 16%, easy in 76%, difficult in 5%, and very difficult in 3%. The SLIPA™ proved to be a reliable airway providing adequate ventilation in both spontaneous breathing and assisted respiration. Most users found the SLIPA™ to be easy or very easy to use.

Clinical application of limiting laryngeal mask airway cuff pressures utilizing inflating syringe intrinsic recoil

BACKGROUND

Overinflation of the laryngeal mask airway (LMA) cuff may cause many of the complications associated with the use of the LMA. There is no clinically acceptable (cost effective and practical) method to ensure cuff pressure is maintained below the manufacturer's recommended maximum value of 60 cm H2O (44 mmHg). We studied the use of the intrinsic recoil of the LMA inflating syringe as an effective and practical way to limit cuff pressures at or below the manufacturer's recommended values.

METHODS

We enrolled 332 patients into three separate groups: LMAs inserted and inflated per standard practice at the institution with only manual palpation of the pilot balloon; LMA cuff pressures measured by a pressure transducer and reduced to < 60 cm H2O (44 mmHg); and LMA intra-cuff pressure managed by the intrinsic recoil of the syringe.

RESULTS

There were no statistically significant differences between the pressure transducer group and the syringe recoil group for initial cuff pressure or cuff pressure 1 hour after surgery. Both the syringe recoil group and pressure transducer group were less likely than the standard practice group to have sore throat and dysphagia 1 hour after surgery. These differences remained 24 hours after surgery.

CONCLUSIONS

Syringe recoil provides an efficient and reproducible method similar to manometry in preventing overinflation of the LMA cuff and decreasing the incidence of postoperative laryngopharyngeal complications.

Comparison of I-gel versus Endotracheal Tube in Patients Undergoing Elective Cesarean Section: A Prospective Randomized Control Study

Background and Aim:

Physiological changes during pregnancy and the sympatho adrenalstimulation during larynoscopy and intubation leads to evaluation of safe devices to secure airway during cesarean section under general anesthesia. I-gel, recently emerging effective supra glottic device found safe during general anesthesia in cesarean section. Aim of the study is to compare the hemodynamic disturbances and airway related complications of I-gel and Endotracheal tube in patients undergoing cesarean section under general anesthesia.

Material and Methods:

Eighty ASA II pregnant patients posted for elective LSCS were randomly divided into two groups of 40 each (n = 40). According to the group they were inserted either I-gel (Group I) or ETT (Group E). Insertion time, ease of intubation, hemodynamics during insertion and Extubation, airway related complications like sore throat, blood on the device, dysphagia, regurgitation, nausea, vomiting, aspiration and laryngospasm were noted and compared. Statistical analysis was done by using unpaired t test, chi square test and fisher's test. P value of <0.05 was considered as significant.

Results:

The demographic parameters, ease of insertion, insertion times and adequacy of ventilation were comparable between the groups (P > 0.05). 8 out of 40 patients in Group E had difficult intubation (P < 0.01). More than 20% of rise in MAP and HR were found during intubation and Extubation in Group E (40 out of 40 patients) which was statistically significant when compared to Group I (P < 0.001). Post operative sore throat significantly high in Group E (30 out of 40) (P < 0.001) when compared to Group I (4 out of 40).

Conclusion:

Easier insertion with less hemodynamic disturbances and very low incidence of sore throat I-gel found to be safer device to secure the airway in patients undergoing LSCS under general anesthesia.

Comparison of effects of ProSeal LMA™ laryngeal mask airway cuff inflation with air, oxygen, air:oxygen mixture and oxygen:nitrous oxide mixture in adults: A randomised, double-blind study

Background and Aims:

Laryngeal mask airway (LMA) cuff pressure increases when the air is used for the cuff inflation during oxygen: nitrous oxide (O₂:N₂O) anaesthesia, which may lead to various problems. We compared the effects of different gases for ProSeal LMA™ (PLMA) cuff inflation in adult patients for various parameters.

Methods:

A total of 120 patients were randomly allocated to four groups, according to composition of gases used to inflate the PLMA cuff to achieve 40 cmH₂ O cuff pressure, air (Group A), 50% O₂ :air (Group OA), 50% O₂:N₂O (Group ON) and 100% O₂ (Group O). Cuff pressure, cuff volume and ventilator parameters were monitored intraoperatively. Pharyngolaryngeal parameters were assessed at 1, 2 and 24 h postoperatively. Statistical analysis was performed using ANOVA, Fisher's exact test and step-wise logistic regression.

Results:

Cuff pressure significantly increased at 10, 15 and 30 min in Group A, OA and O from initial pressure. Cuff pressure decreased at 5 min in Group ON (36.6 ± 3.5 cmH₂ O) (P = 0.42). PLMA cuff volume increased in Group A, OA, O, but decreased in Group ON (6.16 ± 2.8 ml [P < 0.001], 4.7 ± 3.8 ml [P < 0.001], 1.4 ± 3.19 ml [P = 0.023] and − 1.7 ± 4.9 ml [P = 0.064], respectively), from basal levels. Ventilatory parameters were comparable in all four groups. There was no significant association between sore throat and cuff pressure, with odds ratio 1.002.

Conclusion:

Cuff inflation with 50% O₂:N₂O mixture provided more stable cuff pressure in comparison to air, O₂ :air, 100% O₂ during O₂:N₂O anaesthesia. Ventilatory parameters did not change with variation in PLMA cuff pressure. Post-operative sore throat had no correlation with cuff pressure.

Airway Complications during and after General Anesthesia: A Comparison, Systematic Review and Meta-Analysis of Using Flexible Laryngeal Mask Airways and Endotracheal Tubes

OBJECTIVE

Flexible laryngeal mask airways (FLMAs) have been widely used in thyroidectomy as well as cleft palate, nasal, upper chest, head and neck oncoplastic surgeries. This systematic review aims to compare the incidence of airway complications that occur during and after general anesthesia when using the FLMA and endotracheal intubation (ETT). We performed a quantitative meta-analysis of the results of randomized trials.

METHODS

A comprehensive search of the PubMed, Embase and Cochrane Library databases was conducted using the key words "flexible laryngeal mask airway" and "endotracheal intubation". Only prospective randomized controlled trials (RCTs) that compared the FLMA and ETT were included. The relative risks (RRs) and the corresponding 95% confidence intervals (95% CIs) were calculated using a quality effects model in MetaXL 1.3 software to analyze the outcome data.

RESULTS

Ten RCTs were included in this meta-analysis. There were no significant differences between the FLMA and ETT groups in the incidence of difficulty in positioning the airway [RR = 1.75, 95% CI = (0.70-4.40)]; the occurrence of sore throat at one hour and 24 hours postoperative [RR = 0.90, 95% CI = (0.13-6.18) and RR = 0.95, 95% CI = (0.81-1.13), respectively]; laryngospasms [RR = 0.58, 95% CI = (0.27-1.23)]; airway displacement [RR = 2.88, 95% CI = (0.58-14.33)]; aspiration [RR = 0.76, 95% CI = (0.06-8.88)]; or laryngotracheal soiling [RR = 0.34, 95% CI = (0.10-1.06)]. Patients treated with the FLMA had a lower incidence of hoarseness [RR = 0.31, 95% CI = (0.15-0.62)]; coughing [RR = 0.28, 95% CI = (0.15-0.51)] during recovery in the postanesthesia care unit (PACU); and oxygen desaturation [RR = 0.43, 95% CI = (0.26-0.72)] than did patients treated with ETT. However, the incidence of partial upper airway obstruction in FLMA patients was significantly greater than it was for ETT patients [RR = 4.01, 95% CI = (1.44-11.18)].

CONCLUSION

This systematic review showed that the FLMA has some advantages over ETT because it results in a lower incidence of hoarseness, coughing and oxygen desaturation. There were no statistically significant differences in the difficulty of intubation or in the occurrence of laryngospasms, postoperative sore throat, airway displacement, aspiration or laryngotracheal soiling. However, there was a higher incidence of partial upper airway obstruction in the FLMA than in the ETT group. We conclude that the FLMA has some advantages over ETT, but surgeons and anesthesiologists should be cautious when applying the mouth gag, moving the head and neck, or performing oropharyngeal procedures to avoid partial upper airway obstruction and airway displacement. The FLMA should not be used on patients at high risk for aspiration.

Postoperative Respiratory Complications of Laryngeal Mask Airway and Tracheal Tube in Ear, Nose and Throat Operations

BACKGROUND

Supraglottic devices could be used to reduce postoperative respiratory complications, but there are few studies focused on their use in more prolonged surgeries.

OBJECTIVES

In this study, we compared postoperative respiratory complications in patients with prolonged ear, nose and throat (ENT) surgeries, whose airways were controlled with tracheal tube or laryngeal mask airway (LMA).

MATERIALS AND METHODS

In a randomized control trial (RCT), 171 candidates of prolonged ENT surgeries were randomly assigned into two groups. In group one (n = 85) LMA and in group two (n = 86) endotracheal tube were used for airway control. The incidences of four postoperative respiratory complications including sore throat, hoarseness, cough and shortness of breath in immediate postoperative period were measured and compared among patients of each group.

RESULTS

Sore throat was recorded in 32.9% of patients with LMA and 44.2% of intubated patients, but it was not statistically significant (Fisher's Exact test = 0.158). Hoarseness was recorded in 3.5% of patients with LMA and 24.4% of intubated patients (Fisher's Exact test = 0.000). In 1.2% of patients with LMA cough was recorded; it was also seen in 7% of the intubated patients (Fisher's Exact test = 0.005). Shortness of breath was mentioned by two intubated patients (2.3%) and in patient with LMA we did not record this complication.

CONCLUSIONS

LMA in prolonged ENT surgeries was associated with reduced respiratory complications.

Laryngeal mask placement in a teaching institution: analysis of difficult placements

Background: Laryngeal mask airway (LMA) placement is now considered a common airway management practice. Although there are many studies which focus on various airway techniques, research regarding difficult LMA placement is limited, particularly for anesthesiologist trainees. In our retrospective analysis we tried to identify predictive factors of difficult LMA placement in an academic training program.

Methods: This retrospective analysis was derived from a research airway database, where data were collected prospectively at the Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA, from 2008 to 2010. All non-obstetric adult patients presenting for elective surgery requiring general anesthesia, were enrolled in this study: anesthesiology residents primarily managed the airways. The level of difficulty, number of attempts, and type of the extraglottic device placement were retrieved.

Results: Sixty-nine unique Laryngeal Mask Airways (uLMAs) were utilized as a primary airway device. Two independent predictors for difficult LMA placement were identified: gender and neck circumference. The sensitivity for one factor is 87.5% with a specificity of 50%. However with two risk factors, the specificity increases to the level of 93% and the sensitivity is 63%.

Conclusion: In a large academic training program, besides uLMA not been used routinely, two risk factors for LMA difficulty were identified, female gender and large neck circumference. Neck circumference is increasingly being recognized as a significant predictor across the spectrum of airway management difficulties while female gender has not been previously reported as a risk factor for difficult LMA placement.

Dysphagia, hoarseness, and globus in a postoperative patient

Sore throat, hoarseness, and dysphagia are known and recognized postoperative complications of laryngeal mask airway use during operative procedures. The patient's symptoms, present immediately after surgery, are thought related to airway manipulation. Airway foreign bodies, although low on the differential, can cause similar symptoms. We present a case of a single patient who presented to a tertiary care center after an elective outpatient procedure with postoperative sore throat, hoarseness, and dysphagia. A foreign body was found lodged in the patient's hypopharynx. The differential diagnosis of sore throat, hoarseness, and dysphagia in the postoperative patient is explored in further detail.

Comparison of the size 3 and size 4 ProSeal™ laryngeal mask airway in anesthetized, non-paralyzed women: a randomized controlled trial

PURPOSE

Based on experimental results, various authors have advocated a size 4 ProSeal™ laryngeal mask airway (PLMA) in preference to a size 3 PLMA for women given a neuromuscular blocking agent because the larger size provided a better airway seal. However, spontaneously breathing patients may be ventilated adequately with a lower seal pressure than that needed for mechanical ventilation. Therefore, a smaller size might be preferable as its reduced bulk possibly induces less mucosal damage in non-paralyzed patients.

METHODS

A total of 152 females undergoing general anesthesia for short outpatient gynecological surgeries were randomly allocated in equal numbers to insertion of a size 3 or 4 PLMA. The insertion time, success rate, seal pressure, hemodynamic variables, and complications, such as blood staining and sore throat, were evaluated.

RESULTS

The incidence of blood staining was lower with the size 3 PLMA compared to the size 4 PLMA (18 vs. 36 %; P = 0.028). Compared with the size 3 LMA, the size 4 PLMA resulted in higher fluctuations in both blood pressure (P = 0.003) and heart rate (P = 0.01). The insertion time was shorter with the size 3 PLMA (9 vs. 16 s; P < 0.001). The airway seal pressure with the size 3 PLMA, although lower than that of the size 4 PLMA (23 vs. 28 cmH2O; P = 0.001), was sufficient for spontaneous ventilation.

CONCLUSIONS

Due to the reduced incidence of mucosal injury and greater hemodynamic stability, the size 3 PLMA may be preferable to the size 4 PLMA for non-paralyzed females.

Gender differences in sore throat and hoarseness following endotracheal tube or laryngeal mask airway: a prospective study

Background

Postoperative sore throat and hoarseness are common minor complications following airway manipulation. This study was primarily done to determine gender differences in the incidence of these symptoms and the location of POST after laryngeal mask airway (LMA) and endotracheal tube (ETT).

Methods

A total of 112 men and 185 women were included during a four month period. All patients were evaluated postoperatively and after 24 hours about the occurrence of sore throat, its location and hoarseness. If the patients had any symptom, they were followed-up at 48, 72 and 96 hours until the symptoms resolved.

Results

There was no significant gender difference in postoperative sore throat (POST) and postoperative hoarseness (PH) when analyzing both airway devices together. The incidence of sore throat and hoarseness were higher postoperatively after an ETT than an LMA (32% vs. 19%, p = 0.012) and 57% vs. 33% (p < 0.001) respectively. Significantly more women than men had POST after an LMA (26% vs. 6%, p = 0.004). No significant gender difference was found in either POST or PH after an ETT or in the incidence of PH after an LMA. More patients located their pain below the larynx after an ETT vs. an LMA (24% vs. 4%). Pain above the larynx was more common after an LMA than an ETT (52% vs. 37%).

Conclusions

In a clinical setting where women are intubated with a smaller size ETT than men, there were no significant differences in POST or PH between genders. Additionally, more women than men have POST when an LMA is used. Awareness of POST and PH may help streamline patients in whom the best airway device could be used during anesthesia and surgery.

The Effect of Flurbiprofen on Postoperative Sore Throat and Hoarseness After LMA-ProSeal Insertion: A Randomised, Clinical Trial

OBJECTIVE

We hypothesized that flurbiprofen lozenges reduce the ProSeal laryngeal mask airway (LMA) related symptoms of Post Operative Sore Throat (POST), hoarseness and dysphagia compared to placebo lozenges.

METHODS

Eighty American Society of Anesthesiologists (ASA) I-II patients undergoing general anaesthesia with LMA were included in this prospective, randomized, placebo-controlled clinical and single centre (university hospital) study. Group F received an 8.75 mg flurbiprofen lozenge (Strefen(®)) and Group P received a placebo lozenge 45 minutes before the induction of anaesthesia. Postoperative sore throat, hoarseness and dysphagia were evaluated 30 minutes after removal of the LMA in the recovery room and then at 4, 12 and 24 h after surgery using a 4-point scale. Data were analysed using Student's t test, and Fisher's exact and Mann-Whitney U tests. A p value of <0.05 was considered statistically significant.

RESULTS

The 8.75 mg flurbiprofen lozenges reduced the severity of early (30 mins) POST and dysphagia. The severity of dysphagia at 4 h and hoarseness at 12 h were also significantly reduced in Group F. There were no significant differences betweeen the groups regarding incidence of sore throat, dysphagia and hoarseness throughout the study period.

CONCLUSION

Preoperative flurbiprofen lozenges reduce the severity of early postoperative sore throat and dysphagia.

Comparison of laryngeal mask airway supreme and laryngeal mask airway proseal for laryngopharyngeal trauma and postoperative morbidity in children

BACKGROUND AND OBJECTIVES

Laryngeal mask airway (LMA), which has been used frequently in airway management, can cause laryngopharyngeal injury and morbidity. In this trial, we compare the macroscopic changes on laryngopharyngeal structures and the postoperative laryngopharyngeal morbidity by using LMA supreme with LMA proseal in children.

METHODS

We divided patients into two groups. We inserted size three LMA proseal into the first group and size three LMA supreme into the second group. Before LMA insertion and after LMA removal, we performed direct laryngoscopy on the patients. We compared hyperemia, mucosal injury and blood staining on LMA removal, as well as insertion time, rate of success in gastric tube insertion on the first attempt, nausea, vomiting, and sore throat between the two groups.

RESULTS

We recorded no significant differences between the two groups for mean operation time, sex, age, weight, rate of success in gastric tube insertion on first attempt, nausea, vomiting, sore throat and mucosal injury. Mean insertion time for the LMA proseal group was significantly longer than the LMA supreme group (p = 0.0001). The ratio of blood staining on LMA removal was significantly higher in the LMA proseal group than the LMA supreme group (p = 0.034). The patients with blood staining on LMA removal exhibited significantly more mucosal hyperemia and injury than the patients with clear LMA (p = 0.0001, p = 0.020).

CONCLUSION

LMA supreme insertion is faster and easier than LMA proseal and causes less laryngopharyngeal injury than LMA proseal in children.

Failure of the Laryngeal Mask Airway Unique™ and Classic™ in the Pediatric Surgical Patient

Background:

Although predictors of laryngeal mask airway failure in adults have been elucidated, there remains a paucity of data regarding laryngeal mask airway failure in children.

Methods:

The authors performed a retrospective database review of all pediatric patients who received a laryngeal mask anesthetic at their institution from 2006 to 2010. Device brands were restricted to LMA Unique™ (Cardinal Health, Dublin, OH) and LMA Classic™ (LMA North America, San Diego, CA), and primary outcome was laryngeal mask failure, defined as any airway event requiring device removal and tracheal intubation. Potential risk factors were analyzed with both univariate and multivariate techniques and included medical history, physical examination, surgical, and anesthetic characteristics.

Results:

Of the 11,910 anesthesia cases performed in the study, 102 cases (0.86%) experienced laryngeal mask failure. Common presenting features of laryngeal mask failures included leak (25%), obstruction (48%), and patient intolerance such as intractable coughing/bucking (11%). Failures occurred before incision in 57% of cases and after incision in 43%. Independent clinical associations included ear/nose/throat surgical procedure, nonoutpatient admission status, prolonged surgical duration, congenital/acquired airway abnormality, and patient transport.

Conclusions:

The findings of the study support the use of the LMA Unique™ and LMA Classic™ as reliable pediatric supraglottic airway devices, demonstrating relatively low failure rates. Predictors of laryngeal mask airway failure in the pediatric surgical population do not overlap with those in the adult population and should therefore be independently considered.

Comparison of clinical performance of the I-gel with LMA proseal

Aim:

To compare insertion characteristics of 2 different supraglottic devices [I-gel and Proseal laryngeal mask airway (PLMA)] and to observe any associated complications.

Study Design:

This prospective, randomized study was conducted in 80 patients [Group I - I-gel insertion (n = 40) and Group P - LMA Proseal insertion (n =40)] of ASA grades I/II, of either sex in the age group 18-65 years. Both groups were compared with respect to ease of insertion, insertion attempts, fiberoptic assessment, airway sealing pressure, ease of gastric tube placement, and other complications.

Materials and Methods:

All patients were asked to fast overnight. Patients were given alprazolam 0.25 mg orally at 10 p.m. the night before surgery and again 2 hours prior to surgery with 1-2 sips of water. Glycopyrrolate 0.2 mg, metoclopramide 10 mg, and ranitidine 50 mg were administered intravenously to the patients 45 minutes prior to the surgery. Once adequate depth of anesthesia was achieved either of the 2 devices, selected using a random computerized table, was inserted by an experienced anesthesiologist. In group I, I-gel was inserted and in patients of group P, PLMA was inserted.

Statistical Analysis:

Student t-test and Mann-Whitney test were employed to compare the means; for categorical variables, Chi-square test was used.

Result:

Mean insertion time for the I-gel (11.12 ± 1.814 sec) was significantly lower than that of the PLMA (15.13 ± 2.91 sec) (P = 0.001). I-gel was easier to insert with a better anatomic fit. Mean airway sealing pressure in the PLMA group (29.55 ± 3.53 cm H₂O) was significantly higher than in the I-gel group (26.73 ± 2.52 cm H₂O; P = 0.001). Ease of gastric tube insertion was significantly higher in the I-gel group (P = 0.001). Incidence of blood staining of the device, sore throat and dysphagia were observed more in PLMA group. No other complications were observed in either of the groups.

Effect of Continuous Cuff Pressure Regulator in General Anaesthesia with Laryngeal Mask Airway

Postoperative pharyngolaryngeal complications (PPLC) occur during anaesthesia due to increased cuff pressure following the insertion of laryngeal mask airways. The use of a pressure regulator to prevent PPLC was evaluated in a prospective, randomized study. Sixty patients scheduled to receive general anaesthesia were randomly assigned to two equal groups of 30, either with or without the regulator. The ‘just seal’ cuff pressure (JSCP), cuff pressure at 5-min intervals during anaesthesia, incidence of pharyngeal sore throat (PST), dysphagia, dysphonia and other complications were evaluated at 1 and 24 h postoperatively. The combined mean ± SD JSCP of both groups was 20.3 ± 3.2 mmHg. In the group with the regulator, cuff pressure was maintained at a constant level during anaesthesia. This study demonstrated that the regulator is a simple, functional device that can reduce the incidence of PST significantly at 1 h postoperatively, following general anaesthesia.

Insertion of the ProSeal laryngeal mask airway is more successful with the 90 degrees rotation technique

PURPOSE

The 90 degrees rotation technique for inserting the ProSeal laryngeal mask airway (PLMA) in anesthetized paralyzed patients was compared with the index finger insertion technique.

METHODS

One hundred twenty Asian adult patients were randomly allocated to either a standard technique group or a rotation technique group. A PLMA size 4 was used for women and size 5 was used for men. In the standard technique group (n = 60), the PLMA was inserted using the index finger. In the rotation technique group (n = 60), the entire cuff of the PLMA was placed in the patient's mouth in a midline approach without finger insertion, rotated 90 degrees counter clockwise around the patient's tongue, advanced and then rotated back until resistance was felt. The primary outcome was success at first insertion. Secondary outcome measures were insertion time and complications.

RESULTS

The success rate at first insertion was greater for the rotation technique group than for the standard technique group (100% vs 83%, respectively; P = 0.003), and less time was required (11 +/- 3 sec vs 19 +/- 16 sec, respectively; P = 0.03). The incidence of postoperative sore throat was lower for the rotation technique group than for the standard technique group (12% vs 33%, respectively; P = 0.009), and blood staining on the PLMA was less (8% vs 40%, respectively; P < 0.001).

CONCLUSION

The 90 degrees rotation technique for inserting the PLMA is more successful than the standard index finger insertion technique. It is associated with fewer side effects, such as blood on the PLMA and sore throat, which suggests it causes less pharyngeal trauma.

Larynxmaske

Introduction of the laryngeal mask airway (LMA) has been a revolutionary development in airway management over the last decades. It was first used clinically in 1981 by A. Brain and has been widely used in Germany since 1990. Originally intended as a substitute for conventional mask respiration for short periods of general anaesthesia, the laryngeal mask is in the meantime used in many areas as an alternative to elective endotracheal intubation as well as an option for controlling difficult airways. This contribution provides an overview of the basics as well as practical aspects of LMA use, and discusses the possibilities and limitations of the laryngeal mask in daily practice.

A heated humidifier does not reduce laryngopharyngeal complaints after brief laryngeal mask anesthesia

PURPOSE

Warming and humidification of inspired gases is standard care for intubated patients whose lungs are ventilated mechanically for prolonged periods. We examined whether active humidification of inspired gases might reduce laryngo-pharyngeal discomfort in patients undergoing brief laryngeal mask airway (LMA) anesthesia.

METHODS

In a prospective trial, 200 adult patients undergoing elective surgery under general anesthesia were randomly assigned to receive ventilation without airway warming and exogenous humidification (Group C-control), or active warming and humidification of inspired gases (Group HUM-humidified), using a humidifier with a heated wire circuit. Inhalational anesthesia was maintained via a circle system. The temperatures and relative humidities of inspired gases were monitored continuously throughout surgery. Postoperative sore throat, dysphonia, and dysphagia were assessed one and 24 hr after anesthesia. Whenever symptoms were present, their severities were graded using a 101-point numerical rating scale.

RESULTS

The mean temperature and relative humidity of the inspired gases in Group HUM were greater compared to Group C (36.1+/-0.4 degrees C and 99.5+/-0.5% vs 26.9+/-0.8 degrees C and 76.4+/-10.9%, respectively). Postoperatively, the overall frequencies of laryngeal and pharyngeal discomfort were similar in the two groups (53.8% and 54.9% in Group C vs 51.6% and 41.9% in Group HUM at one and 24 hr respectively, P>0.05). The groups were also similar with respect to the severity scores of laryngo-pharyngeal discomfort.

CONCLUSION

Active warming and humidification of inspired gases has no clinically appreciable effect in reducing the incidence and severity of laryngo-pharyngeal complaints after brief (<two hours) LMA anesthesia.

A clinical comparison of the Laryngeal Tube™ and the Laryngeal Mask™ in spontaneously breathing anesthetized patients

Abstract: Background: The laryngeal mask airway (LMA) can be used in general anaesthesia without neuromuscular block. The laryngeal tube (LT) is a new airway device with similar airway features as LMA. LT is provided with a distal cuff to prevent regurgitation. In this study we compared the LMA and LT concerning patient and user aspects.

Methods: Sixty patients with ASA (American Society of Anestesiologists) score 1–2 scheduled for minor surgery were randomized to be ventilated either through LMA or LT. After insertion, the number of insertion attempts, and “positioning” and “airway-assessment” was evaluated. The patients reported on “sore throat” after 30 and 60 minutes and the day after anaesthesia.

Results: Gender and mean age were equal in both groups. The first insertion attempt was successful in 25 of 28 patients randomised to LMA and in 23 of 27 patients randomised to LT. LMA was evaluated to be easier in “positioning” whereas no difference in “sore throat” was reported.

Conclusion: We found no difference between the LMA and the LT in terms user and patient friendliness and safety.

Optimal End-Tidal Sevoflurane Concentration for the Removal of the Laryngeal Mask Airway in Anesthetized Adults

Sevoflurane provides smooth and rapid emergence from anesthesia and can be used when the removal of a laryngeal mask airway (LMA) is required in anesthetized patients. We sought to determine the optimal end-tidal concentrations of sevoflurane required for the removal of LMA in anesthetized adults. We studied 35 adults, aged 22-64 years old with an ASA physical status I or II, who were undergoing perineal surgery. General anesthesia was induced with thiopental, and the LMA was then inserted. Anesthesia was maintained with sevoflurane, oxygen, and air. After the surgery, the target concentration was maintained for at least 10 min, and then the LMA was removed. Each target concentration at the time of removal was predetermined by the Dixon up-down method (with 0.1% as a step size) starting at 1.7% end-tidal concentration of sevoflurane. The LMA removal was considered successful when there was no coughing, clenching of teeth, or gross purposeful movements during or within 1 min after removal and also if there was no breath holding, laryngospasm, or desaturation after removal. The end-tidal concentration of sevoflurane to achieve successful LMA removal in 50% of adults was 0.99% +/- 0.09% (mean +/- SD) and in 95% of adults was 1.18% (95% confidence limits, 1.07%-1.79%). In conclusion, we have determined that LMA removal in 50% and 95% of anesthetized adults can be safely accomplished without coughing, moving, or any other airway complications at 0.99% and 1.18% end-tidal concentrations of sevoflurane.

IMPLICATIONS

Because the removal of the laryngeal mask airway (LMA) in the anesthetized state is required in some clinical situations, we sought to determine the end-tidal concentration of sevoflurane to safely remove the LMA in anesthetized adults.

Sex-based ProSeal laryngeal mask airway size selection: a randomized crossover study of anesthetized, paralyzed male and female adult patients

We compared the Size 4 and 5 ProSeal laryngeal mask airway (PLMA) in men and the Size 3 and 4, and 4 and 5 PLMA in women in terms of 1) ease of insertion, 2) oropharyngeal leak pressure (OLP), 3) ease of ventilation at a tidal volume of 10 mL/kg, 4) gas exchange, 5) location of gas leak, 6) anatomic position of the airway and drain tube, and 7) mucosal injury. Thirty male and 60 female (ASA physical status I-II; 18-80 yr old) anesthetized, paralyzed patients were studied in a crossover fashion in three equal-sized groups. PLMA insertion was performed by a single experienced operator by using digital manipulation. In male patients comparing the Size 4 and 5, OLP was higher (P = 0.0002) and leak fraction lower (P = 0.03) for the Size 5, but the number of insertion attempts, insertion time, mucosal injury, anatomic position, gas exchange, and location of gas leak were similar. In female patients comparing the Size 4 and 5 PLMA, OLP was higher for the Size 5 (P < 0.0001), but the number of insertion attempts was fewer (P = 0.02), insertion time was quicker (P = 0.02), and there was less mucosal injury (P = 0.01) with the Size 4. There were no differences in anatomic position, gas exchange, or location of gas leak. In female patients comparing the Size 3 and 4 PLMA, OLP was higher (P = 0.0005) and leak fraction was lower (P = 0.03) for the Size 4, but the number of insertion attempts, insertion time, mucosal injury, anatomic position, gas exchange, and location of gas leak were similar. There were no episodes of failed oxygenation, failed ventilation, or gastric insufflation. We conclude that if size is selected by sex, the Size 4 PLMA is preferable for women and the Size 5 PLMA for men.

IMPLICATIONS

When sex is used to select the appropriate size of the ProSeal laryngeal mask airway, the Size 4 ProSeal is preferable for women and the Size 5 ProSeal for men.

Traumatic complications of intubation and other airway management procedures

Complications arising from intubation and other airway management procedures can have significant morbidity and mortality risks. With the increasing interventional techniques employed by the anesthesiologist to acquire and maintain an airway, there is a potential for increasing airway injury. Awareness of the potential "difficult" airway and employing the appropriate techniques to maximize airway visualization can minimize the risk of these complications.