Letters to Editor References Aiello G, Metcalf I Anaesthetic implications of temporomandibular joint disease Can J Anaesth 1992;39:610-6 Kulkarni DK, Prasad AD, Rao SM Experience in fiberoptic nasal intubation for temporomandibular joint ankylosis Ind J Anaesth 1999;43:26-9 Maassen R, Lee R, Hermans B, Marcus M, van Zundert A A comparison of three videolaryngoscopes; the Macintosh laryngoscope blade reduces, but does not replace, routine stylet use for intubation in morbidly obese patients Anesth Analg 2009;109:1560-5 Behringer EC, Kristensen MS Evidence for benefit vs novelty in new intubation equipment Anaesthesia 2011;66, Suppl 2:57-64 Mahajan R, Shafi F, Sharma A Use of Shroeder’s directional stylet to enhance navigability during nasotracheal intubation J Anesth 2010;24:150-1 Access this article online Quick response code Figure 1: Schroeder’s directional stylet in endotracheal tube aiding entry into the glottis using D-blade of the C-Mac videolaryngoscope to achieve blind nasotracheal intubation of a patient with temporomandibular joint ankylosis.[5] The curvature of the ETT could now be easily changed with the use of SDS, and the tip of the ETT entered between the vocal cords fairly easily [Figure 1] but impacted in the vestibule of the larynx Withdrawing the SDS and raising the head slightly helped in negotiation of the impacted ETT into the trachea Correct tracheal intubation was further confirmed by capnography During this procedure with the C-Mac videolaryngoscope, the patient was administered 2% sevoflurane in 100% oxygen via a 14 gauge catheter attached to the side channel of the C-MAC blade Oxygen saturation, mean arterial pressure and heart rate remained between 97 and 99%, 68 and 98 mmHg and 88 and102/min, respectively In conclusion, a combination of D-blade of the C-Mac videolaryngoscope and Schroeder’s directional stylet may provide an alternative strategy for tracheal intubation in patients with restricted mouth opening, with the added advantage of oxygenation during intubation Abdullah M Al-Jadidi, Rashid M Khan, Sujit V Nair, Naresh Kaul Department of Anaesthesia and ICU, Khoula Hospital, Muscat, Sultanate of Oman Address for correspondence: Dr Naresh Kaul, Department of Anaesthesia and ICU, National Trauma Centre, Khoula Hospital, PO Box 514, Postal Code 118, Al Harthy Complex, Sultanate of Oman E-mail: drnareshkaul@gmail.com Indian Journal of Anaesthesia | Vol 56| Issue | Jul-Aug 2012 Website: www.ijaweb.org DOI: 10.4103/0019-5049.100840 Anaesthetic management of an infant with vallecular cyst: A challenging situation Sir, Congenital vallecular cyst, although rare, is an important condition leading to stridor and complete airway obstruction in infants, which may be precipitated by various factors such as feeding, crying, induction of anaesthesia or even during awake fibreoptic bronchoscopy Different techniques have been described in the literature for securing the airway, and each one has its own merits and demerits We report one such case in which the airway could not be secured by any of the conventional techniques described for such cases; thus, necessitating tracheostomy A 3-month-old male baby weighing 2.5 kg presented with coughing and vomiting following feeds and failure to thrive The respiratory rate was 38/min, with minimal intercostal recession There was no cyanosis or stridor Oxygen saturation on room air was 98% Diagnosis of vallecular cyst was made after computed tomography scan of the neck [Figure 1] 423 Letters to Editor Vallecular cyst, although benign, carries a potential threat of hypoxia and death if not managed appropriately.[1] Laryngomalacia is associated in 90% of cases.[2] After reviewing the literature, it was observed that no specific technique has been clearly outlined for such a tricky situation All techniques, such as paraglossal laryngoscopy, awake fibreoptic bronchoscopy, inhalation induction and even intubation after muscle relaxation and cyst aspiration, have been attempted.[3-5] Paraglossal laryngoscopy has been successfully executed in two cases.[3,4] Figures 1: Computed tomography scan of the vallecular cyst The child was scheduled for excision of the cyst An inhalation induction with intubation was planned Surgeons were asked to be standby for emergency tracheostomy, considering the high risk of loosing the airway and non-availability of a neonatal fibreoptic bronchoscope An intravenous line was secured after induction of anaesthesia with halothane in 100% oxygen After confirming mask ventilation, 5 mg propofol was supplemented and laryngoscopy attempted with Miller size laryngoscope introduced by a paraglossal approach; but, a cystic swelling was visible in front of the tip of the blade that could not be deflected to either side or lifted up Immediately, a decision to perform tracheostomy was made However, as tracheostomy was being performed, mask ventilation became difficult and oxygen saturation dropped to 70% Pink frothy secretions were noted in the oral cavity and nostrils suggestive of negative pressure pulmonary oedema The patient’s neck was extended and turned to the right to facilitate ventilation thereby improving the saturation to 90% Meanwhile, a size 3 uncuffed tracheostomy tube was secured in place Ventilation was facilitated by mg atracurium After this, the saturation rose to 98% and the chest cleared gradually Anaesthesia was maintained with isoflurane in oxygen and µg fentanyl A check laryngoscopy was carried out to assess if muscle relaxation improved the glottic view, but neither the epiglottis nor the arytenoids could be visualised The cyst was excised by an extraoral approach Residual neuromuscular blockade was reversed and the baby was shifted to the Intensive Care Unit for further observation The trachea was decannulated after 2 weeks and the baby has been doing well since Parental consent was obtained for publication of this clinical scenario for educational purposes 424 A pre-operative awake fibreoptic bronchoscopy under local anaesthesia may appear to be the safest technique, but is difficult even in expert hands because of the limited space available for manipulation of the scope in the hypopharynx and distorted laryngeal anatomy Moreover, the danger of airway obstruction still remains in the case of failure of fibreoptic bronchoscopy.[3] In light of these facts and the absence of stridor and cyanosis in an otherwise active infant, we decided to secure the airway by a paraglossal technique after inhalation induction Paraglossal laryngoscopy failed to reveal any laryngeal structure This could be attributed to the fact that the cyst was adherent to the epiglottis, which could not be lifted Although muscle relaxants have been used to facilitate laryngoscopy, a high incidence of associated laryngomalacia and fear of airway collapse and complete airway obstruction precluded the use of muscle relaxants in our case Cyst aspiration can be associated with a risk of pulmonary aspiration, increased recurrence rate and difficulty in identifying cyst margins upon subsequent surgery.[3] Hence, a decision to establish a surgical airway was made for cyst excision Tracheostomy in an infant itself is a demanding skill on the part of the surgeon due to difficult anatomy and precarious respiratory reserve To conclude, anaesthetic management of infants with vallecular cysts requires meticulous planning and individualised approach Guiding factors for the anaesthetic plan are age and pre-operative symptomatology of the child, size and location of the cyst and, above all, expertise of the anaesthesiologist and facilities at hand for paediatric airway management Preparedness for tracheostomy should always be present, especially in the absence of a neonatal fibreoptic bronchoscope, as surgical airway Indian Journal of Anaesthesia | Vol 56| Issue | Jul-Aug 2012 Letters to Editor may be the only option left, especially in an emergency situation Upma Bhatia Batra, Suniti Kale, Amita Malik1 Departments of Anaesthesiology and Intensive Care, 1Department of Radiodiagnosis, VMMC, Safdarjung Hospital, New Delhi, India Address for correspondence: Dr Upma Bhatia Batra, Departments of Anaesthesiology and Intensive Care VMMC, Safdarjung Hospital, New Delhi, India E-mail: ubhatia2004@gmail.com References Gutierrez JP, Berkowitz RG, Robertson CF Vallecular cysts in newborns and infants Pediatr Pulmonol 1999;27:282-5 Liu HC, Lee KS, Hsu CH, Hung HY Neonatal vallecular cyst: Report of eleven cases Changgeng Yi Xue Za Zhi 1999;22:615-2 Cheng KS, Li HU, Hartigan PM Vallecular cyst and laryngomalacia in infants: Report of six cases and airway management Anesth Analg 2002;95:1248-50 Kalra S, Saraswat N, Kaur R, Agarwal RA Vallecular cyst in a newborn: A challenging airway management Anaesth Intensive Care 2011;3:509-10 Gandhi S, Raza SA, Thedekar P, Mishra P Congenital vallecular cyst with laryngomalacia: A report of two cases J Laryngol Voice 2011;1:27-9 Access this article online Quick response code Website: www.ijaweb.org DOI: 10.4103/0019-5049.100842 Should ultrasonography check be routinely done following removal of femoral vascular catheter in patients with end-stage renal disease? Sir, With the increasing use of femoral vascular catheter in intensive care unit (ICU), the insertion related complications of them are dealt seriously.[1,2] But, scarcity of reports about complications following removal of femoral vascular catheter encourage us to report two interesting, potentially fatal complications of femoral vascular catheter removal in end-stage Indian Journal of Anaesthesia | Vol 56| Issue | Jul-Aug 2012 renal disease (ESRD) patients The importance of bedside ultrasonography (USG) after femoral vascular catheter removal has been stressed in this communication Case A 22-year-old student was transferred to our ICU with hospital-acquired pneumonia with ESRD due to obstructive uropathy On admission, he was conscious, haemodynamically stable, tracheostomised on mechanical ventilation and pale (haemoglobin gm/dl) He had mildly deranged prothrombin time (3 seconds prolonged) and normal platelet count He had left femoral dialysis catheter (DC) (12 Fr, 18 cm, Mahurkar) in situ Since, the insertion site was erythematous, we removed DC No oozing was visible A new DC was placed in right femoral vein uneventfully under USG guidance Two days later, patient complained of left thigh pain His left thigh and groin area was found warm, tender and slightly swollen Urgent bedside USG and Doppler of that region showed large haematoma (12×10 cm) just posterior to the femoral vessels with intact vascular flow [Figure 1] The patient developed septic shock with haemoglobin drop (6 gm/dl) on next day In view of increasing groin swelling and impending compartment syndrome, surgical drainage was arranged A large haematoma and pus was removed Microbiology revealed growth of Staphylococcus aureus-sensitive to vancomycin from the pus and contemporary blood cultures He showed clinical improvement within 48 hrs of intravenous vancomycin therapy Case A 72-year-old obese retired nurse, with hypertensive heart disease and ESRD was referred to our ICU for extensive cellulitis of the left leg leading to septic shock For invasive blood pressure monitoring, we put a right femoral arterial catheter (7 Fr, Certofix mono, B Braun) uneventfully under USG guidance However, the patient recovered from septic shock within days Her haemoglobin, prothrombin time and platelet counts came to normal limits Decision was made to remove the femoral catheter After days of removal of catheter, patient complained of right thigh pain On palpation, some indurations were felt A bedside lower limb USG showed a large haematoma anterior to common femoral artery, approximately 120-ml volume A lower limb computed tomography angiogram [Figure 2] showed a pseudoaneurysm 425 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 ... Anesth Analg 2002;95:1248-50 Kalra S, Saraswat N, Kaur R, Agarwal RA Vallecular cyst in a newborn: A challenging airway management Anaesth Intensive Care 2011;3:509-10 Gandhi S, Raza SA, Thedekar... respiratory reserve To conclude, anaesthetic management of infants with vallecular cysts requires meticulous planning and individualised approach Guiding factors for the anaesthetic plan are age and... vallecular cyst: Report of eleven cases Changgeng Yi Xue Za Zhi 1999;22:615-2 Cheng KS, Li HU, Hartigan PM Vallecular cyst and laryngomalacia in infants: Report of six cases and airway management Anesth