Direct laryngoscopy should be procedure of choice in the airway management of patients with dental cellulitis.

Feb 2012

Boccheciampe N, Hell-Remy C, Le Manach Y, Andrieu G, Riou B, Bertolus C, Langeron O.

Source

From the Department of Anaesthesiology and Critical Care (NB, YLM CHR, GA, OL), Department of Emergency Medicine and Surgery (BR) and Department of Maxillofacial Surgery (CB), CHU Pitié-Salpêtrière, Paris, France.

Abstract

CONTEXT:

Airway management of patients with dental cellulitis can be difficult due to laryngeal deviation and oedema. Awake fibre-optic intubation has been recommended.

OBJECTIVE:

The aim of this study was to assess our routine procedure which is based mainly on direct laryngoscopy.

DESIGN:

This was a prospective observational study.

SETTING:

In a single centre between February 2008 and February 2009.

PATIENTS:

All patients suffering from dental cellulitis and requiring emergency surgery were included except pregnant women and patients under 18 years.

INTERVENTION:

Nasotracheal intubation by direct laryngoscopy under general anaesthesia was performed unless the supine position was not tolerated, or difficult mask ventilation or intubation was anticipated, when awake nasotracheal fibre-optic intubation was indicated. In the case of failure at the first attempt, orotracheal intubation by direct laryngoscopy was attempted. If failure persisted, tracheotomy was then performed.

MAIN OUTCOME MEASURES:

The principal endpoint was the incidence of difficult mask ventilation which was expected to be less than 5%. Secondary endpoints were the incidence of difficult tracheal intubation and tracheotomy.

RESULTS:

We included 127 consecutive patients (mouth opening 20 ± 10 mm). One did not tolerate the supine position and was successfully intubated using the fiberscope. Among the 126 remaining, difficult mask ventilation did not occur [0%, 95% confidence interval (CI) 0-3%], 124 (98%) patients were intubated by direct laryngoscopy and two (2%) required tracheotomy. Retrognathia (odds ratio 8.2, 95% CI 1.3-50.1) and extension to oral floor (odds ratio 15.1, 95% CI 1.8-129.5) were significantly associated with the prediction of intubation failure at the first attempt.

CONCLUSION:

Most patients with dental cellulitis can be safely intubated through direct laryngoscopy even if mouth opening is limited.

European Journal of Anesthesiology