[Difficult intubation managed by laryngeal mask and fibroscopy]

A case is reported of a patient due to undergo a combined kidney and pancreas transplant who proved to be difficult to intubate. This diabetic hypertensive 35-year-old male patient also had ankylosing spondylitis. Mouth opening was normal (more than fingers' breadth), the chin-sternum distance was 4 cm on full cervical flexion, and cervical extension was only slightly impaired. The Mallampati score was 1. Anaesthesia was induced with thiopentone, fentanyl and 6 mg of pancuronium. Mask ventilation was quite satisfactory. However, on laryngoscopy, the vocal cords could not be seen. Several attempts to carry out endotracheal intubation, including with a stylet, failed. A laryngeal mask (LM) was therefore applied to ventilate the patient correctly. It was not possible to pass a small endotracheal tube (6 mm diameter) through the LM tube, probably because of a small malposition of this latter. A paediatric fibroscope, passed through the LM tube, served as guide for the endotracheal tube. The mask was not removed, although its cushion was slightly deflated, so as not to extubate the patient. The benefits and usefulness of a laryngeal mask in predictable and unpredictable cases of difficult intubation are discussed.