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

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.