CASE REPORT Difficult Retrograde Endotracheal Intubation: The Utility of a Pharyngeal Loop Virendra K. Arya, MD, Amitabh Dutta, MD, Pramila Chari, MD, MNAMS, FAMS, and Ramesh K. Sharma, MS, Mch* Departments of Anaesthesia & Intensive Care and *Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India D irect laryngoscopy and tracheal intubation re- mains the technique of choice to achieve control of the airway. Alternative or additional tech- niques of airway control are required whenever an airway is deemed difficult because of anatomical and/or technical reasons. The retrograde intubation technique is an important option for gaining airway access from below the vocal cords in such situations (1). We report successful management and the prob- lems encountered while gaining the upper airway by the retrograde catheter method in a patient having bilateral fibrous ankylosis of the temporomandibular joint (TMJ). Case History A cooperative 30-yr-old female patient (52 kg, 154 cm, ASA physical status I) was admitted to the hospital for plastic reconstruction and redo-release of bilateral fibrous ankylosis of TMJ. One year previous, when she underwent release of ankylosis under general anesthesia (GA), control of airway had been extremely difficult. A tracheostomy was per- formed during local anesthesia as repeated, awake, blind nasal, and retrograde intubation attempts failed. This time, examination of the airway revealed no mouth opening with a minimal gap between the overriding incisors, no move- ments at both the TMJs, severe retrognathia, and mentothy- roid and mentohyoid distances of 3.0 and 2.2 cms respec- tively (Fig. 1 and 2). Both nares were patent. Neck mobility was normal. Lateral neck radiograph demonstrated a mini- mal inter-incisor gap, severe retrognathia, prominent gonial notch, submandibular tongue and epigllotic shadow, and long air shadow of extended oropharynx in direct alignment with the esophagus (Fig. 3). There was no history of hoarse- ness of voice, breathlessness, difficulty in swallowing, or frequent sleep awakenings at night. In view of airway difficulty during the previous anes- thetic, posttracheostomy status, and nonavailability of a fi- beroptic bronchoscope, tracheal intubation with awake ret- rograde technique was planned. After explanation of the procedure, an informed consent was obtained from the patient. Preoperatively, the patient was prepared with aspiration prophylaxis, nasal decongestants, and IM glycopyrrolate. Oral diazepam 5 mg was given 1 h before the procedure. Routine monitoring was applied and bilateral superior la- ryngeal nerve blocks for the upper airway anesthesia were performed. Topical anesthesia of the nares and nasopharynx was performed with 10% lidocaine spray. The cricothyroid membrane was punctured with a 14-gauge venous cannula and tracheal lumen confirmed by air aspiration. A radio- opaque ureteral guidewire (0.89 mm150 cm, Terumo- Europe N.V., 3001 Leuven, Belgium) was advanced retro- gradely through it and was intended to exit via the nares. This failed repeatedly and resistance to advancement was felt. The guidewire was withdrawn and a 16-gauge epidural catheter was used in its place to prevent airway trauma. It also failed to come out through the patient’s nose but could be advanced with ease. On close observation it was visible through the minimal inter-incisor gap as coiled in the oral cavity. It was extracted with the help of a Joseph skin hook (Fig. 4). Thereafter, a Ryle’s tube (nasogastric tube) was passed through the right nare and advanced with cricoid pressure to make it coil in the oral cavity and make it possible to remove it orally. This was performed with the intent to retrieve the epidural catheter through the nares with the Ryle’s tube. However, the Ryle’s tube could not be removed through the inter-incisor gap after multiple at- tempts and may have gone straightaway into the esophagus on each occasion. We then used a self-made pharyngeal loop device to help extract the Ryle’s tube through the mouth. The ureteral guidewire was threaded through a 3-mm un- cuffed polyvinyl chloride (PVC) endotracheal tube and dou- bled up to form a loop (Fig. 4, 5). By pushing the free end of the guidewire, the loop diameter could be altered (Fig. 6). This assembly was gently passed into the oral cavity through the minimal inter-incisor gap. Once inside, the loop was expanded to the maximum to touch the pharyngeal wall circumferentially. The Ryle’s tube was again passed via the nare. After advancing it sufficiently, the pharyngeal loop was gently tightened and withdrawn slowly through the inter-incisor gap. With this maneuver we were able to bring out the Ryle’s tube orally. Afterwards, the epidural catheter Accepted for publication September 18, 2001. Address correspondence and reprint requests to Virendra K. Arya, MD, Assistant Professor, Department of Anaesthesia & Inten- sive Care, PGIMER, Chandigarh-160012, India. Address e-mail to aryavk_99@yahoo.com. ©2002 by the International Anesthesia Research Society 470 Anesth Analg 2002;94:470–3 0003-2999/02