Ultrasound-Guided Airway Evaluation: Is It a Game Changer for Predicting Difficult Endotracheal Intubation?

INTRODUCTION: Airway ultrasound has recently promised to be a valuable addition to preoperative airway assessment tools. This study was undertaken to determine the efficacy of ultrasound-guided measurement of soft tissue thickness (STT) at various levels of the anterior neck in predicting difficult airways in an eastern Indian population. OBJECTIVE:  The primary objective was to find out the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of anterior neck soft tissue thickness at the level of the hyoid (STT-Hyoid) and vocal cords (STT-VC), distance from the skin to the epiglottis midway (DSEM), and the ratio of the depth of the pre-epiglottic space (Pre-E) to the distance from the epiglottis to the mid-point of the vocal cords (E-VC). The secondary objective was to develop a scoring system using these parameters. MATERIALS AND METHODS: One hundred eighty-eight patients aged 18-65 years who received general anesthesia and endotracheal intubation for surgery were included in the study. Anterior neck soft tissue thickness measurements were done preoperatively using ultrasound. The actual difficulty of the airway was graded by the anesthesiologist while performing endotracheal intubation using the intubation difficulty scale (IDS). RESULTS: The incidence of a difficult airway (IDS > 5) was 9.04%. The STT-Hyoid and STT-VC had a moderate correlation with IDS. The DSEM and Pre-E/E-VC ratios had a weak correlation with IDS. For difficult airway prediction, the cutoff points of STT-Hyoid and STT-VC were 7.95 mm and 24.25 mm, respectively. The combined cutoff measurements of STT-Hyoid and STT-VC (29.95 mm) were better predictors of difficult airway. CONCLUSION: Preoperative airway ultrasound examination measuring the soft tissue thickness at the hyoid and vocal cord levels is an effective modality in predicting a difficult airway. However, further studies are needed to validate this finding in populations of varied ethnicity and demographic distribution.

Ganglion Impar Block: A Magic Bullet to Fix Idiopathic Coccygodynia.

Coccygodynia (coccydynia) is a painful condition of the perineum in the region of the tailbone or coccyx, aggravated by sitting on hard surfaces. It is frequently associated with injuries to the coccyx following direct trauma. Nevertheless, idiopathic coccygodynia without antecedent trauma history is not uncommon. Most of these patients respond to anti-inflammatory medications and physical therapy. Those who are unresponsive may require additional intervention for pain relief. Blockade of ganglion impar, the terminal end of the pelvic sympathetic chain, can dramatically alleviate the pain in patients suffering from coccygodynia. In the current case series, four patients in the age range of 21 to 69 years suffering from chronic idiopathic coccygodynia (female: male ratio of 1:1) were treated with ganglion impar block. All four patients received a course of medical management, and two of the patients additionally received local infiltration of the coccyx before ganglion impar block administration. The block was performed with fluoroscopy guidance by either the trans-sacrococcygeal joint approach or the intra-coccygeal joint approach. The pre-intervention average numeric rating pain score (NRS) was 7.5. After a single ganglion impar block intervention, all four patients experienced complete pain relief (NRS=0). No patients required a repeat injection, and all were pain-free for the entire one-year follow-up period.

Perioperative Dystonia Mimicking Convulsion: Awareness Is the Key to Diagnosis.

Dystonia, a variant of acute extrapyramidal symptoms (EPS), is a known side effect of neuroleptics. It is a rare but well-recognized complication in perioperative settings. Most of the reported cases have been linked to the perioperative use of metoclopramide. Dystonic reactions typically present as repetitive movements or abnormal posturing of the head, neck, and body. These reactions usually last only for a few minutes and are rarely lethal. However, occasionally they may present as sustained laryngopharyngeal muscle spasms, potentially leading to fatal airway obstruction. In this report, we present the case of an elderly female patient who developed a life-threatening episode of dystonia mimicking convulsion in the postoperative period. She had received metoclopramide as pre-anesthetic medication before surgery.

Eagle's Syndrome Managed Successfully by Pulsed Radiofrequency Treatment.

Eagle's syndrome is a rare cause of craniofacial pain caused by impingement of adjacent neurovascular elements by an elongated styloid process or by a calcified stylohyoid ligament. There is a wide spectrum of clinical presentations, which encompasses craniofacial pain, oropharyngeal pain, otalgia, headache, and vertigo. Typically, the glossopharyngeal nerve gets entrapped, giving rise to characteristic orofacial pain. The diagnosis of Eagle's syndrome is confirmed radiologically, and the management includes pharmacotherapy and surgical removal of the styloid process. Moreover, minimally invasive interventions in the form of glossopharyngeal nerve block and radiofrequency treatment can also be effective in providing pain relief. We report a case of an elderly male who presented with features of glossopharyngeal neuralgia secondary to an elongated styloid process and was managed successfully with pulsed radiofrequency treatment of the glossopharyngeal nerve.

Comparison of sensitivity, specificity, and accuracy of Wilson's score and intubation prediction score for prediction of difficult airway in an eastern Indian population-A prospective single-blind study.

INTRODUCTION: Unidentified difficult airway leads to significant adverse events and therefore prediction of a difficult airway is of importance. Independent bedside tests for the prediction of a difficult airway have poor accuracy. The airway assessment scores have not gained popularity as they are cumbersome to perform at the bedside. They also have a varying degree of interobserver variability because of their subjective parameters. Therefore, there is a need to search for a simple score with objective parameters that can be performed at the bedside. AIM: To determine the diagnostic accuracy of the Wilson score andiIntubation prediction score for predicting difficult airway in the Eastern Indian population. MATERIAL AND METHOD: A prospective single-blind study was done including 150 consecutive patients, ASA grade I and II between the ages of 18 and 70 years, undergoing surgery requiring general anesthesia with endotracheal intubation. Preoperatively, the airway was assessed in all patients using Wilson Score and Intubation Prediction Score. General anesthesia with endotracheal intubation was done in all patients. The airway was assessed for ease laryngoscopy and intubation using the Intubation Difficulty Scale. An IDS >5 was taken as difficult airway. The sensitivity, specificity, PPV, NPV, and accuracy of the two predictive tests to predict a difficult was calculated. RESULTS: The sensitivity, positive predictive value and accuracy of Intubation Prediction Score was 77.8%, 58.3%and 90.7% respectively as compared to 38.9%, 25.95% and 78.33% respectively of Wilsons score. CONCLUSION: Intubation Prediction score with its objective parameters can be preferred as a simple and accurate bedside test to predict a difficult airway in an Eastern Indian population.

Laryngeal rhinosporidiosis: An airway catastrophe averted.

Rhinosporidiosis is a type of nasal polypoidal growth arising from the mucosa of nasal cavity and often extending to nasopharynx. Occasionally, this growth may invade the lower airways and cause airway obstruction. The clinical presentation of such cases is often contradictory and airway management during induction of anesthesia requires caution to prevent potential life-threatening situations. A case of large pedunculated rhinosporidiosis involving the epiglottis and laryngeal inlet, with significant airway management challenge has been presented here. Clinical significance: Primary care physicians should be diligent in evaluating patients with rhinosporidiosis and look for signs of airway obstruction to rule out lower airway involvement.

Trigeminal Neuralgia in Pregnancy: A Management Challenge.

Pregnancy is known to aggravate pre-existing chronic painful conditions. Trigeminal neuralgia (TN), albeit a disease of the elderly, may afflict pregnant females, which can further complicate its management. Teratogenic effects of the commonly used drugs on the developing fetus limit pharmacological treatment. Moreover, safety of commonly performed interventional therapies is marred by their inherent fetomaternal effects and more importantly the risk for radiation effects on the fetus due to the use of fluoroscopy. This rare coexistence of TN in pregnancy has not been reported before. Here we present a case of TN in a young woman, whose pain was aggravated when she became pregnant, and she was treated successfully by conventional radiofrequency ablation of the Gasserian ganglion.