Letters to Editor Address for correspondence: Dr Rajender Kumar, A-22, Sai Apartment, Plot No 47, Sector-13, Rohini, New Delhi - 110 085, India E-mail: drrbarua@rediffmail.com REFERENCES Saltzman DA, Schmitz ML, Smith SD, Wagner CW, Jackson RJ, Harp S The slipping rib syndrome in children Paediatr Anaesth 2001;11:740-3 Cyriax EF On various conditions that may stimulate the referred pain of visceral diseases and a consideration of these from the point of view of cause and effect Practitioner 1919;102:314-22 Davies-Colley R Slipping rib Br Med J 1922;1:432 Holmes JF Slipping rib cartilage with report cases Am J Surg 1941;54:326-38 Holmes JF A study of the slipping rib-cartilage syndrome N Engl J Med 1941;224:928-32 Udermann BE, Cavanaugh DG, Gibson MH, Doberstein ST, Mayer JM, Murray SR Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report J Athl Train 2005; 40:120-2 Keoghane SR, Douglas J, Pounder D Twelfth rib syndrome: a forgotten cause of flank pain BJU Int 2009; 103:569-70 Machin DG, Shennan JM Twelfth rib syndrome: a differential diagnosis of loin pain BMJ (Clin Res Ed) 1983; 287:586 Access this article online Quick response code Website: www.ijaweb.org DOI: 10.4103/0019-5049.115585 A case of a difficult airway due to large sublingual dermoid in a rural medical college examination revealed a smooth tender immovable mass 3 × 4 cm on the floor of the mouth occupying the entire oral cavity and displacing the tongue against the hard palate making visualization of the tongue difficult There was limited temporomandibular joint movement and normal thyromental distance Lateral X‑ray of neck in the standing position revealed narrowing of the oropharynx [Figure 1] Preoperative indirect laryngoscopy was attempted by the otolaryngologist; however, glottic structures were not visualized Consent for fiberoptic nasal intubation under general anesthesia was obtained and the patient was premedicated with injection Glycopyrolate 0.2 mg i.v and injection Metoclopramide 10 mg i.v 30 min before procedure Emergency invasive airway access was kept ready in the case of failed intubation Pulse oximeter, electrocardiogram, and end tidal carbon dioxide monitors were connected and baseline parameters recorded Injection Fentanyl 100 µgm i.v was given and nasal mucosa anaesthetized with cotton pledgets soaked in 3 ml 4% lignocaine and 0.5 ml xylometazoline After preoxygenation with 100% oxygen for 3 min, anesthesia was induced with halothane in oxygen and nitrous oxide (33:67%) Mask‑assisted ventilation was possible during spontaneous breathing Fiberoptic bronchoscopy through the nasal cavity was performed under spontaneous breathing The fiberoptic view was poor, epiglottis was not visible, hence jaw thrust was provided and vocal cords were visualized Lignocaine 4% was sprayed onto vocal cords Adequacy of inhalational and local anesthesia was verified, scope was advanced under the epiglottis through the vocal Sir, Giant size sublingual dermoid cysts are extremely rare and pose considerable technical challenges to the anesthesiologists We report a case posted for marsupialization of cyst with a tentative diagnosis of congenital ranula and ectopic thyroid as differential diagnosis A 29‑year‑old patient complained of a slow growing swelling inside the mouth, first noticed in childhood The patient complained of pain in the swelling, dysarthria, dysphagia, and mild respiratory distress on lying supine after needle aspiration biopsy Airway Indian Journal of Anaesthesia | Vol 57| Issue | May-Jun 2013 Figure 1: Lateral X-ray of neck in standing position 313 Letters to Editor cords till the carina was visualized A 6.0 mm cuffed endotracheal tube was advanced into the trachea over the scope Oxygenation was adequate throughout intubation Anesthesia was maintained with halothane, oxygen, nitrous oxide, and vecuronium bromide as necessary An intraoperative diagnosis of dermoid was made [Figure 2] At the completion of surgery, direct laryngoscopy showed laryngeal grade view (Cormack and Lehane classification) As supraglottic edema was not anticipated, patient was extubated when fully awake Postextubation vital parameters were within normal range and patient maintained oxygen saturation (SpO2) of 97‑98% in room air Sublingual dermoid cysts account for less than 1% of cystic intraoral lesions and fewer than 225 cases have been reported in the literature.[1] Various airway management strategies have been suggested such as blind nasotracheal intubation, fiberoptic endoscope‑guided intubation and preliminary tracheostomy Blind nasotracheal intubation requires extensive practice prior to use and carries the risk of bleeding and trauma Preliminary tracheostomy significantly increases morbidity Excision under local anesthesia with monitored anesthesia care carries significant risk of intra operative pulmonary aspiration Decompression of dermoid cyst by aspirating its contents prior to intubation to facilitate intubation has been reported.[2] This was not attempted in our case as a preoperative diagnosis was not made and surgical procedures in the airway preceding a definitive diagnosis have the potential for converting an anticipated difficult airway into a dangerously difficult airway.[3‑5] Nasal fiberoptic intubation was chosen as it was not possible to pass both scope and tube in the highly limited oral cavity As the patient refused bronchoscope placement while awake, general anesthesia using volatile anesthetic agents was chosen When spontaneous ventilation is maintained, the changes in depth of anesthesia and associated respiratory and cardiovascular effects occur gradually and can be easily reversed with the use of volatile anesthetic agents.[6] Fiberoptic nasotracheal intubation while maintaining spontaneous breathing under inhaled anesthesia is one of the recommended methods of securing the airway in uncooperative patients with large sublingual dermoid Lavanya Kaparti, T Mahesh Department of Anaesthesiology, PESIMSR, Kuppam, Andhra Pradesh, India Address for correspondence: Dr. Lavanya Kaparti, C 57, Officers Quarters BEML Nagar, Kolar Gold Fields, Kolar ‑ 563 115, Karnataka, India E‑mail: drlavanyakaparti@yahoo.com References King RC, Smith BR, Burk JL Dermoid Cyst in the Floor of the Mouth Review of the Literature and Case Reports Oral Surg Oral Med Oral Pathol 1994;78:567‑76 Raveenthiran V, Sam CJ, Srinivasan SK A simple approach to airway management for a giant sublingual dermoid cyst Can J Anesth 2006;53:1265‑6 Naveen E, Doreen Y Airway management for intra‑oral surgery – airway first Can J Anesth 2007;54:488‑89 Eipe N, Pillai AD, Choudhrie A, Choudhrie R The tongue flap: An iatrogenic difficult airway? Anesth Analg 2006;102:971‑3 Kummer C, Netto FS, Rizoli S, Yee D A review of traumatic airway injuries: Potential implications for airway assessment and management Injury 2007;38:27‑33 Brooks P, Ree R, Rosen D, Ansermino M Canadian pediatric anesthesiologists prefer inhalational anesthesia to manage difficult airways Can J Anesth 2005;52:285‑90 Access this article online Quick response code Website: www.ijaweb.org Figure 2: Maximum mouth opening achieved under general anaesthesia with muscle relaxation 314 DOI: 10.4103/0019-5049.115588 Indian Journal of Anaesthesia | Vol 57| Issue | May-Jun 2013 Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use ... while maintaining spontaneous breathing under inhaled anesthesia is one of the recommended methods of securing the airway in uncooperative patients with large sublingual dermoid Lavanya Kaparti,... Oral Pathol 1994;78:567‑76 Raveenthiran V, Sam CJ, Srinivasan SK A? ?simple approach to airway management for a giant sublingual dermoid cyst Can J Anesth 2006;53:1265‑6 Naveen E, Doreen Y Airway. .. to Editor cords till the carina was visualized A? ?6.0 mm cuffed endotracheal tube was advanced into the trachea over the scope Oxygenation was adequate throughout intubation Anesthesia was maintained