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Mallampatti class 4 to class 1!!
Sir,
A ranula is a retention cyst filled with mucus, occurring as a result of the blockage of a sublingual salivary gland or unnamed glands in the oral cavity.[1] Plunging ranulas associated with or without oral swellings can burrow into the submandibular, submental, and retropharyngeal spaces, lateral aspect of neck, and upper mediastinum. They are usually asymptomatic but rarely cause dysphagia and potential airway obstruction.[2,3]
A 4-year-old boy presented with a history of swelling in the sublingual region gradually increasing in size since 3 years. The patient had difficulty in eating solid food, the mouth was always kept open, and there was excess salivation. On examination, a swelling measuring 5 × 4 cm was seen in the sublingual region extending more to the left side and pushing the tongue into the oral cavity and leaving the mouth open. Airway examination revealed the tongue almost covering the entire oral cavity making the uvula with palatal arch not visible and it graded as a Mallampatti class 4 airway The thyromental distance could not be measured correctly because the swelling was in the submandibular and submental regions. The child was apparently healthy with no respiratory distress and systemic disorders.
The child was scheduled for excision of the cyst. After premedication with atropine 0.4 mg and midazolam 1 mg intravenously (IV), through an IV cannula in situ, the child was shifted to the operating room. Standard monitors were connected and anesthesia was induced with thiopentone. Suxamethonium administered after confirming adequacy of ventilation. Oral tracheal intubation was planned as difficulty in visualization of vocal cords was anticipated. The vocal cords were not visible on direct laryngoscopy with help of a size 2 Macintosh (MAC) blade. As the blade was swept over the tongue, the tip of the blade could not be manipulated into the vallecula beyond the swelling. The tip of the blade could be manipulated beyond the swelling to visualize the posterior commissures of the cords, with an external laryngeal pressure, when an MAC 3 adult-sized blade was used. An uncuffed 5-mm ID endotracheal tube (ETT) with stylet was passed through the vocal cords with difficulty in the second attempt [Figure 1].
We decided to secure the ETT using the nasal route as there was concern of tube coming in surgical field and accidental tracheal extubation during surgical manipulation. Aspiration of the 50 ml of fluid from cyst was done. The swelling was reduced sufficiently in size [Figure 2]. Laryngoscopy was attempted with MAC 2 blade and this time the vocal cords were easily visible (Cormack and Lehanne grade 1) without any external manipulation. Nasal intubation was carried out easily with a 4.5-mm ID uncuffed ETT and the throat packed. Marsupialization of the cyst was done. Tracheal extubation was uneventful.
Surgical management is preferred for most ranulas. Marsupialization is done preserving the sublingual gland and adjacent tissue.[4] Molar intubation or paraglossal techniques, requiring expertise, are advocated when standard laryngoscopy as a large tongue remains anterior to the blade due to a large infraoral swelling.[5]
Use of an MAC 3 adult blade in young children in these situations is required to go beyond the swelling up to the base of the tongue into the vallecula and visualize the epiglottis and then the glottis. In close consultation with the surgical colleague, the feasibility of aspiration of the cystic lesions should be considered, if does not interfere with the plane of dissection. For safe airway management in selective cystic lesions, particularly in the absence of availability of difficult intubation aids, the cyst can be aspirated before tracheal intubation.