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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 45-47

Airway management in huge ranula

1 Department of Anaesthesiology, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India
2 Department of Anaesthesiology and Critical Care, B.R.D. Medical College, Gorakhpur, Uttar Pradesh, India

Date of Submission07-Jan-2021
Date of Acceptance29-Jan-2021
Date of Web Publication29-Apr-2021

Correspondence Address:
Dr. Priyanka Dwivedi
Department of Anaesthesiology, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_3_21

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Airway management in the presence of a large intraoral swelling is always challenging. We report a young boy with a huge ranula occupying the entire oral cavity and protruding from the mouth. Our planned and strategic approach in a resource-limited setting included prior consultation with the ENT surgeon for aspiration of swelling if needed before intubation. Good topical airway anaesthesia followed by gentle videolaryngoscopy resulted in successful airway management.

Keywords: Intraoral swelling, ranula, videolaryngoscope

How to cite this article:
Dwivedi P, Mall S, Ahmad S, Sharma S. Airway management in huge ranula. Airway 2021;4:45-7

How to cite this URL:
Dwivedi P, Mall S, Ahmad S, Sharma S. Airway management in huge ranula. Airway [serial online] 2021 [cited 2021 Jun 20];4:45-7. Available from: https://www.arwy.org/text.asp?2021/4/1/45/315162

  Introduction Top

Ranula is a retention cyst filled with mucous occurring due to blockage of the sublingual or submandibular salivary gland. It can present with or without an oral swelling extending into submandibular, submental and retropharyngeal spaces or lateral aspect of the neck and upper mediastinum, posing a potentially challenging airway to the anaesthesiologist.[1]

A 12-year-old boy weighing 22 kg was admitted with a painless swelling in the floor of the mouth measuring 79 mm × 72 mm × 52 mm extending from the sublingual to submandibular region. The swelling was protruding from the mouth, hindering the visualisation of the uvula and soft palate (modified Mallampati class 4) [Figure 1]a and [Figure 1]b. His general and systemic examinations were unremarkable and so were the laboratory investigations and lateral neck X-ray. A computerised tomographic scan of the head and neck showed a hypodense cystic lesion in the sublingual region extending to the submandibular region [Figure 1]c. After consulting the ENT surgeon for prior aspiration of the cyst to decrease its size if required for facilitating airway access and manipulation, nasal intubation with a videolaryngoscope (Anaesthetics India Pvt Ltd., Model AVL-2P, code: 6360) was planned and a tracheostomy kit was kept in readiness as a backup.
Figure 1: (a and b) Huge ranula protruding from the mouth (front and lateral views); (c) computerised tomographic scan showing hypodense cystic lesion in the sublingual region extending to the submandibular region; (d) patient after successful nasotracheal intubation

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After obtaining informed consent and following 8 h of fasting, the child was shifted to the operating room where an electrocardiogram, noninvasive blood pressure and pulse oximetry were established. An intravenous (IV) line was secured with a 20 SWG cannula and premedication was given with IV glycopyrrolate 0.1 mg, midazolam 0.5 mg, fentanyl 50 µg and ondansetron 2 mg. Xylometazoline drops were instilled in both nostrils and 5 mL of 4% lignocaine was nebulised to reduce airway vascularity and reactivity. After preoxygenation, sevoflurane (up to 7%) along with oxygen: nitrous oxide (40:60) and propofol 30 mg were given for induction. Once the adequate depth of anaesthesia for intubation was achieved, it appeared feasible to introduce a videolaryngoscope without the need of aspiration of the cyst. A gentle videolaryngoscopy was performed and after visualisation of the vocal cords, a well-lubricated 5.5 mm ID cuffed polyvinyl chloride endotracheal tube was introduced gently through the right nostril and guided smoothly with optimal external laryngeal manipulation into the trachea. It was fixed after confirmation of proper position [Figure 1]d. Vecuronium 2.5 mg was given as muscle relaxant and general anaesthesia was maintained with oxygen: nitrous oxide (40:60) and sevoflurane. Oral packing was done by the ENT surgeon. After the completion of the surgery, the patient was successfully extubated. The postoperative period was uneventful.

  Discussion Top

Airway management in huge ranulas or intraoral swellings is always crucial as they encroach and occupy the oral cavity making glottic visualisation by direct laryngoscopy difficult. They are often dealt with using fibreoptic laryngoscopy, blind nasal intubation or aspiration of cyst before airway manipulation.[1],[2],[3] Although awake fibreoptic bronchoscopy is a superior and safer technique for intubation, it is still not universally available. The longer learning curve results in the anaesthesiologist becoming less confident and comfortable in using it as compared to other airway devices. Videolaryngoscopy is another modality currently available for dealing with difficult airways, justifying a place for it in the difficult airway cart.[4] It utilises video-camera technology to visualise airway structures, thereby eliminating the need for a direct line of sight. Videolaryngoscopes are easy to use, less expensive compared to fibre optic scopes, with a shorter intubation time and a success rate and safety profile comparable to fibre optic bronchoscopy.[4],[5]

In our patient, a large soft-tissue swelling occupying the oral cavity rendered intubation with conventional direct laryngoscopy impossible as a direct view of glottis could have been difficult, if not impossible, to obtain. A videolaryngoscope was available in our institution and the paediatric fibreoptic bronchoscope was not working; so we planned a videolaryngoscope-assisted nasal intubation. Aspiration of the cyst and tracheostomy were our backup plans. With the child breathing spontaneously under deep inhalational anaesthesia and prior topical anaesthesia of the airway, videolaryngoscopy was performed smoothly and nasal intubation achieved successfully in the first attempt.

  Conclusion Top

A videolaryngoscope is an important tool in the management of a difficult airway and should always be available in the difficult airway cart.

Declaration of patient consent

The authors certify that they have obtained the appropriate informed consent form. In the form, the parents of the child have given their consent for his images to be reported in the journal. The parents understand that their son's name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Sethi SK, Jain N, Khare A, Patodi V. Anaesthetic management in a case of large plunging ranula with difficult airway: A case report. Egypt J Anaesth 2016;33:209-12.  Back to cited text no. 1
Kumar N, Bindra A, Kumar N, Yadav N, Sharma S. Anesthetic concerns in a huge congenital sublingual swelling obscuring airway access. Saudi J Anaesth 2015;9:202-3.  Back to cited text no. 2
Krishna R, Wali M, Nataraj MS, Shenoy T. Mallampatti class 4 to class 1!! J Anaesthesiol Clin Pharmacol 2012;28:264-5.  Back to cited text no. 3
Myatra SN, Doctor JR. Use of videolaryngoscopy as a teaching tool for novices performing tracheal intubation results in greater first pass success in neonates and infants. Indian J Anaesth 2019;63:781-3.  Back to cited text no. 4
[PUBMED]  [Full text]  
Alhomary M, Ramadan E, Curran E, Walsh SR. Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis. Anaesthesia 2018;73:1151-61.  Back to cited text no. 5


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