Cannot ventilate, difficult to intubate.

EDITOR: We read with interest the letter by Slater and Bhatia [1] and would like to congratulate them on their successful management. We agree that the safest approach for their patient would have been an awake fibreoptic intubation. However, we would like to make a few comments. From the history and picture, it is not clear whether the patient had a prosthesis fitted into the left orbital cavity. If so it could have deceived the airway assessment at preoperative visit. Difficult mask ventilation is, however, still appreciable as it appears to be impossible to achieve a seal with the face mask. In addition to this, a history of radiotherapy associated with limited mouth opening are ominous signs. Although the patient has had an anaesthetic for grommet insertion, it is possible that a spontaneously ventilating technique with a laryngeal mask airway (LMA) was used. If that was the case, the airway remains unchallenged after the radiotherapy following the initial craniofacial resection. We therefore believe that an awake fibreoptic intubation would have been a safer choice of securing the airway in the first place. Once the situation of inability to ventilate the patient with a face mask was rescued by the LMA, the difficulty with intubation could have been dealt with one of the two options. Firstly, the trachea could have been blindly intubated via the size 5 LMA. Blind tracheal intubation via the laryngeal mask has been reported [2] and it is recognized as one of the alternative approaches for tracheal intubation in the ASA difficult airway management algorithm [3]. However, the Difficult Airway Society guidelines draw attention to the fact that the classic LMA is not designed for this purpose and does not recommend blind intubation via the classic LMA. The other option is fibreoptic-assisted intubation through the LMA, which may have a higher chance of success [4]. Secondly, an intubating laryngeal mask airway (ILMA) could have been used. Intubation could then have been blind via the ILMA or under direct vision using the fibreoptic scope. This technique has been used in patients in whom tracheal intubation using traditional methods had failed and also when other known or anticipated intubation difficulties were expected. Using an Aintree catheter with assisted fibreoptic intubation via these supraglottic devices is also reported and well recognized [5–7]. By adopting any of these techniques the oxygenation would have been uninterrupted via a dedicated patent airway while allowing tracheal intubation. It would then have been possible to avoid the nasal route.