Background: To evaluate the possibility of airway management using a laryngeal mask airway (LMA) during dental procedures on mentally retarded (MR) patients and patients with genetic diseases. 
Design: A prospective pilot study. 
Setting: University Hospital. 
Methods: A pilot study was designed to induce general anaesthesia for dental procedures in 15 mentally retarded patients, with airway management using a laryngeal mask airway (LMA). The parameters assessed during the pilot study included ease of LMA insertion and its seal, inspiratory pressures with controlled ventilation, visibility of the operating field and surgical comfort, recovery from anaesthesia, LMA tolerability and postoperative complications. 
Results: LMA insertion was successful in all of the patients, operating field visibility was good in most patients, as was tolerability, and awakening was uneventful. Serious postoperative complications bleeding, prolonged coughing and eating disorders were not observed. 
Conclusions: In this pilot study, the LMA was a suitable tool for airway management during dental procedures on the mentally retarded and on patients with genetic diseases.
Keywords: Dental care, Mentally disabled persons, Genetic diseases, Laryngeal mask airway
Southern African Journal of Anaesthesia & Analgesia Vol.10(4) 2004: 15-1

Kieslochova, E

Michalek, P

Rocen Jr, M

Scigel, V

English

AJOL - African Journals Online

RESEARCHSouthern African Journal of Anaesthesia & Analgesia - October 2004 15The Laryngeal Mask Airway (LMA) as analternative to airway management inmentally retarded patients during dentalprocedureslead to anxiety or aggressiveness of the mentally retarded pa-tient, and refusal to take food.3 The aim of the present pilotstudy was to test laryngeal mask airway management in out-patient dental procedures in the MR patient and in individualswith upper airway abnormalities due to genetically related syn-dromes.MethodsOver a period of 30 months (between 2001 and 2003), a totalof 30 mentally retarded patients required dental care undergeneral anaesthesia (out of a total number of 42 registeredpatients) at the Dental Care Unit for At-Risk Patients of thePrague-based Institute for Clinical and Experimental Medi-cine. Six patients were managed using spontaneous ventila-tion without any further airway management, 8 were intubatedwhilst the LMA was used in 15 (Table I). The diagnoses ofpatients in the LMA group are summarized in Table 1. Thepilot group consisted of 7 women and 8 men, with a mean ageof 27 years (range, 15-42 years). This pilot study was approvedby the Ethics Committee of the institution.Correspondence:Dr P Michalekemail: pavel.michalek@homocka.czOutpatient dental care of the severely mentally retarded pa-tient requires the induction of general anaesthesia, mainly be-cause of their complete lack of cooperation. For years, thegold standard for these procedures has been orotracheal ornasotracheal intubation, with general anaesthesia, using con-trolled or intermittent mandatory ventilation. Use of conscioussedation, a common procedure in adult patients, is almost im-possible in the mentally retarded patient because of the lackof cooperation.1 However, tracheal intubation in these patientsis associated with pitfalls. The altered anatomy of the upperairways, associated with some genetic abnormalities (e.g.Down's syndrome and “cri-du-chat'” syndrome) may result inproblems with tracheal intubation.2 Nasotracheal intubationmay cause bleeding and contamination of the tube with thenasal cavity content. Post-intubation pain in the throat mayP Michalek1, V Scigel2, E Kieslichova3, M Rocen Jr.31 Department of Anesthesia and Intensive Care, Na Homolce Hospital, Prague, Czech Republic2 Dental Outpatient Care for At-Risk Patients, Institute for Clinical and Experimental Medicine, Prague, Czech Republic3 Department of Anesthesia and Intensive Care, Institute for Clinical and Experimental Medicine, Prague, Czech RepublicAbstractBackground: To evaluate the possibility of airway management using a laryngeal mask airway (LMA) during dental procedures on mentally retarded(MR) patients and patients with genetic diseases. Design: A prospective pilot study. Setting: University Hospital. Methods: A pilot study was designedto induce general anaesthesia for dental procedures in 15 mentally retarded patients, with airway management using a laryngeal mask airway (LMA).The parameters assessed during the pilot study included ease of LMA insertion and its seal, inspiratory pressures with controlled ventilation, visibility ofthe operating field and surgical comfort, recovery from anaesthesia, LMA tolerability and postoperative complications.  Results: LMA insertion wassuccessful in all of the patients, operating field visibility was good in most patients, as was tolerability, and awakening was uneventful. Seriouspostoperative complicationsæbleeding, prolonged coughing and eating disordersæwere not observed. Conclusions: In this pilot study, the LMA was asuitable tool for airway management during dental procedures on the mentally retarded and on patients with genetic diseases.Key words: dental care, mentally disabled persons, genetic diseases, laryngeal mask airwayRESEARCHSouthern African Journal of Anaesthesia & Analgesia - October 2004 16Those indicated for general anaesthesia using the LMA included:• Patients in whom tracheal intubation is expected to cause prob-lems (previous experience, known or presumed anatomicalabnormalities)• A difficult-to-examine patient scheduled for a procedure of anunspecified type and extent.All patients were examined preoperatively, and were given oralpretreatment using dehydrobenzoperidole (2 mL) and atropine(0.5 mg). Anaesthesia was induced in ten patients intravenouslyusing propofol, sufentanil and low-dose suxamethonium (0.3mg.kg-1). The LMA was inserted after the induction of generalanaesthesia. These patients showed a modicum of cooperation,and allowed us to insert an intravenous cannula. The remainingfive patients were given inhaled sevoflurane first, followed byperipheral venous cannulation. An appropriately-sized laryngealmask airway (sizes 3-5) was inserted, following the administra-tion of suxamethonium at a dose of 0.3 mg.kg-1. Anaesthesia wasmaintained with an O2 and N2O (nitrous oxide) mixture andsevoflurane. Patients were monitored using pulse oximetry, non-invasive blood pressure measurement, and electrocardiogram(ECG). Circuit pressure (inspiratory, expiratory and plateau) lev-els were also monitored. The LMA was fixed in the corner of themouth opposite to that used for the surgical procedure. A tam-ponade (throat pack) was also established in the hypopharynx.The following parameters were assessed:• Ease of laryngeal mask insertion (assessed using a four-pointscale: 1 = easy insertion at first attempt; 2 = LMA insertedafter repeated attempts, no leakage; 3 = LMA inserted afterrepeated attempts, good seal on spontaneous ventilation, leak-age on controlled ventilation; 4 = the mask does not seal afterrepeated attempts• Inspiratory pressure on controlled ventilation• Visibility of the operative field and level of comfort for thesurgeon• Recovery from general anaesthesia, LMA tolerability, airwayirritation, coughing, retching• Postoperative complications: circulatory instability, respira-tory depression, neck pain, bleeding, refusal of food intakeResultsThe surgical procedure was successfully performed on 15 pa-tients using the LMA. Five patients had multiple tooth extrac-tions, whilst four had conservative treatment of dental caries; sixmentally retarded patients underwent more extensive combinedprocedures.In most patients LMA insertion was uneventful and success-ful at the first attempt. Only two patients required repeated LMAinsertion and the LMA had to be replaced by another size in onepatient. There was no LMA leakage in 14 patients whereas mini-mal leakage could be heard with one laryngeal mask during con-trolled ventilation. Inspiratory pressures on controlled ventila-tion were below 2 kPa (1-1, 8 kPa) in all patients. The laryngealmask insertion and seal were also uneventful in the 7 patientswith altered upper respiratory tract anatomy due to genetically-related diseases with predicted (or previous) difficult intubation.The surgeon rated the operating field visibility as very good in 11cases, and as somewhat poorer in 4 cases. In no patient was thescheduled surgical procedure reduced because of poor oral cav-ity visibility. The laryngeal mask was very well tolerated duringanaesthesia. Awakening was calm in all patients, there was noaggressiveness, confused motion, coughing and retching. Fivepatients removed the LMA by themselves after awakening; theother 7 were fully awake and tolerated the presence of the LMAin the hypopharynx. The LMA was removed by theanaesthesiologist.No patient experienced serious perioperative complicationssuch as circulatory instability, hypoventilation, aspiration or ap-nea. One patient required short-term (30 minute) supplementaloxygenation via a face mask. In the postoperative course, onepatient developed a transient bout of coughing (2 days). Hoarse-ness, bleeding complications, sore throat, and refusal of food in-take were not observed.DiscussionThis pilot study shows a relatively simple and feasible methodfor airway management of mentally retarded patients and thosewith genetic diseases undergoing dental procedures.The LMA is a standard tool for airway management duringshort- and medium-term procedures.4 It took a long time be-fore it came into routine use for procedures in the oral cavity,primarily because of the risk of dislodgment and poor visibil-ity of the operating field. In recent years, reports have beenpublished on a series of patients undergoing oral surgery withthe help of airway management using the LMA, such as ton-sillectomy, mandibular surgery and dental procedures.5-8 Theadvantages of the LMA are self-evident: insertion does notrequire other instruments, manipulation is easy and quick, thereis minimal intraoperative laryngoscope-caused damage to den-tition, bleeding from nasal cavities and lower airway infec-tion, as well as injury to the vocal cords. In the postoperativeTable I: The primary diagnoses in the patients undergoing dental procedureswith LMADiagnosis Number of patientsDown syndrome 5Posthypoxic encephalopathy 3Idiopathic mental retardation 6Cri-du-chat syndrome 1Total number 15Figure 1: LMA inserted in a patient with Down's syndrome and macroglossiaRESEARCHSouthern African Journal of Anaesthesia & Analgesia - October 2004 17period the LMA significantly reduced the risk of laryngospasm,laryngeal and tracheal bleeding, coughing, and sore throats.In addition, the LMA can be used in patients expected to causedifficulty during intubation as a result of modified anatomicalupper airway circumstances. However, the LMA has severaldrawbacks when used in oral cavity procedures including ri-gidity, increased potential for dislodgment compared with thetracheal tube, and reduced oral cavity visibility, compared withnasotracheal intubation. The LMA does not completely ruleout the potential risk for aspiration, and its use may be associ-ated with compression of the nerve structures in the oral cav-ity and hypopharynx.8-9Use of the laryngeal mask in mentally retarded patients andin those with genetic anomalies has not been investigated sys-temically. There have only been case reports and small seriesof fewer than 5 patients.8,10 A mentally retarded patient is sel-dom able to undergo a procedure with analgosedation or con-scious sedation, cooperating with the surgeon. These patientsare usually anxious, wary of aliens, oversensitive to painfulstimuli and unable to communicate.1 Often it is not even pos-sible to perform a dental examination prior to the procedurewithout general anaesthesia. In these patients, general anaes-thesia is usually induced using orotracheal intubation. How-ever, it is extremely difficult to perform tracheal intubation insome mentally retarded patients with genetic abnormalities.Down's syndrome patients (chromosome 21 trisomy) oftenhave macroglossia, laryngomalacia, congenital subglotticstenosis and tracheal stenosis.11 These patients are often diag-nosed as having lymphoid hyperplasia; and one of its forms,referred to as lingual tonsillar hypertrophy, may cause life-threatening airway obstruction.12 Successful airway manage-ment in these patients using the LMA has also been reported.13LMA insertion has likewise been successful in our Down'ssyndrome patients. Another genetic syndrome associated withupper airway anomalies is the “cri-du-chat” syndrome (dele-tion of part of the short arm of chromosome 5). It is character-ized by mental retardation, micrognathia, anatomical abnor-malities of the larynx, hypotonia, and congenital heart dis-ease.14 Laryngeal mask insertion in the patient with the “cri-du-chat” syndrome was also successful in our cohort.Our pilot study shows that anaesthesia with airway man-agement using the LMA is well tolerated by mentally retardedpatients; it was also successfully inserted in patients with up-per airway pathology. Postoperative complications, includingrefusal of food intake, which may pose a considerable chal-lenge in patients following tracheal intubation, were minimalin our series.ConclusionThe laryngeal mask has proved to be an option of choice inairway management in short-term outpatient conservative anddental procedures under general anaesthesia in several men-tally retarded patients and in those with genetic syndromesassociated with anatomical oral cavity and upper airway ab-normalities. The LMA allows for quick and simple airwaymanagement, particularly in mentally retarded patients whowill not even allow preoperative oral cavity examinations,making the extent of procedure unclear. Procedures to be un-dertaken in several quadrants and on the MR patient withmacroglossia result in poor visibility of the operating field.To improve protection against aspiration, a gauze tamponadein the hypopharyx is advisable. Still, further, larger studiesare warranted to define more accurate indications and algo-rithms for LMA use in the mentally retarded patient in dentalcare.References1. C Stiles. Anesthesia for the mentally retarded patients. Ortho ClinNorth Am 1981; 12:45-56.2. MG Butler, BG Hayes, MM Hathaway, ML Begleiter. Specific ge-netic diseases at risk for sedation/anesthesia complications.Anesth Analg 2000; 91:837-55.3. J Roeters, R Burgersdijk. The need for general anesthesia for thedental treatment of mentally handicapped patients: a follow upstudy. ASDC J Dent Child 1985; 52:344-6.4. AB Leach, CA Alexander. Laryngeal maskæan overview. Eur JAnaesthesiol 1991; 4:19-31.5. JD Hern, SM Jayaraj, VS Sidhu et al. The laryngeal mask airway intonsillectomy: the surgeon’s perspective. Clin Otolaryngol 1999;24:122-5.6. JR Brimacombe, A Berry. The laryngeal mask airway for dentalsurgery – a review. Aust Dent J 1995; 40:10-14.7. Bennett J, Petito A, Zandsberg S. Use of the laryngeal mask air-way in oral and maxillofacial surgery. J Oral Maxillofac Surg 1996;54:1346-51.8. CC Chen, WT Hung, CM Liou. Evaluation of airway leakage usingreinforced laryngeal mask during dental anesthesia with sponta-neous breathing. Acta Anaesthesiol Sin 2002; 40:21-4.9. JR Brimacombe. Problems with the laryngeal mask airway: pre-vention and management. Int Anesthesiol Clin 1998; 36:139-54.10. N Sculerati, M Gottlieb, M Zimbler, Airway management in chil-dren with major craniofacial anomalies. Laryngoscope 1998;108:1806-12.11. SR Shott. Down syndrome: analysis of airway size and a guide forappropriate intubation. Laryngoscope 2000; 110:585-92.12. K Nakazawa, D Ikeda, S Ishikawa, K Makita. A case of difficultairway due to lingual tonsillar hypertrophy in a patient with Down'ssyndrome. Anesth Analg 2003; 97:704-5.13. BW Fundingsland, JL Benumoff. Difficulty using a laryngeal air-way in a patient with lingual tonsil hyperplasia. Anesthesiology1996; 84:1265-6.14. RP Brislin, SA Stayer, RE Schwartz. Anaesthetic considerationsfor the patient with cri du chat syndrome. Paediatr Anaesth 1995;5:139-41.

The Laryngeal Mask Airway (LMA) as an alternative to airway management in mentally retarded patients during dental procedures: research

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The Laryngeal Mask Airway (LMA) as an alternative to airway management in mentally retarded patients during dental procedures: research

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