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Year : 2014  |  Volume : 8  |  Issue : 1  |  Page : 114-116  

Anaesthetic management in a case of huge plunging ranula

Departments of Anaesthesiology and Critical Care, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India

Date of Web Publication15-Mar-2014

Correspondence Address:
Sarbari Swaika
Department of Anesthesiology and Critical Care, Bankura Sammilani Medical College and Hospital, Bankura - 722 102, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0259-1162.128929

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Plunging ranula is a rare form of mucous retention cyst arising from submandibular and sublingual salivary glands, which may occasionally become huge occupying the whole of the floor of the mouth and extending into the neck, thus, restricting the neck movement as well as disfiguring the normal airway anatomy. Without fiberoptic assistance, blind or retrograde nasal intubation remains valuable choices in this type of situation. Here, we present a case of successful management of airway by blind nasal intubation in a patient posted for excision of a huge plunging ranula.

Keywords: Blind nasal intubation, fiberoptoc intubation, huge plunging ranula

How to cite this article:
Sheet J, Mandal A, Sengupta S, Jana D, Mukherji S, Swaika S. Anaesthetic management in a case of huge plunging ranula. Anesth Essays Res 2014;8:114-6

How to cite this URL:
Sheet J, Mandal A, Sengupta S, Jana D, Mukherji S, Swaika S. Anaesthetic management in a case of huge plunging ranula. Anesth Essays Res [serial online] 2014 [cited 2021 Feb 28];8:114-6. Available from:

   Introduction Top

Ranula is a retention cyst filled with mucous, occurring as a result of the blockage of the sublingual salivary gland or unnamed glands in the oral cavity. Plunging ranulas are associated with or without oral swelling, can burrow into the submandibular, submental, retropharyngeal spaces, lateral aspect of the neck and upper mediastinum which may pose potential airway obstruction, [1] leading to difficulty in airway management.

   Case Report Top

This was a case report of a 20-year-old male patient, with weighing 56 kg, was admitted to our hospital with a painless huge, tense swelling of around 12 cm × 10 cm size in the floor of the mouth. The mass was gradually increasing in size and extending to the submental and submandibular region occupying the upper anterior part of the neck [Figure 1]. He had a history of discomfort while eating and difficulty in deglutition, speech and sleep for 6 months. The intraoral part of the mass was extending more toward the left, deviating the tongue toward right and making the uvula and soft palate invisible thus graded as Mallampati IV [Figure 2].
Figure 1: External view of ranula

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Figure 2: Intraoral view

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The general and systemic examinations revealed no abnormality. On evaluation of airway, the mouth opening was three fingers, thyromental distance could not be assessed due to the position of the swelling, Mallampati was graded IV [2] and there was slight restriction of neck movement. Nasal patency was checked using cotton wisp. [3]

Routine investigations were within normal limit including bleeding time and coagulation time. Indirect laryngoscopy, done by ear, nose and throat surgeon, was found to be normal. Lateral X-ray neck showed soft-tissue shadow at upper part of the neck and computed tomography scan of the neck showed a cystic lesion with septae not involving any part of trachea or larynx [Figure 3]. Excision of ranula was planned under general anesthesia after awake nasal intubation as the first line of airway management and retrograde intubation was thought as the second line of management, keeping tracheostomy as back up.
Figure 3: Computed tomography scan of ranula

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Patient was explained and reassured about the technique of anesthesia. He was kept fasting for overnight. Premedication was given with glycopyrrolate, ranitidine and ondansetron after intravenous cannulation in the operating room.

Patient was supine in sniffing position and standard American Society of Anesthesiologists monitors were attached. Transmucosal topical anesthesia of nasal passages was performed by gentle insertion of two cotton tipped applicator sticks soaked in lidocaine-phenylephrine mixture (4% lidocaine and 1% phenylephrine) into each nostril. [4] Patient was nebulized with 5 ml of 4% lidocaine solution and bilateral superior laryngeal nerves were blocked with 3 ml 1% lidocaine. Finally, the trachea was topically anesthetized by instilling 3 ml 4% lidocaine by cricothyroid puncture. [5] A 6.5 mm well lubricated poly vinyl chloride cuffed endotracheal tube (ETT) was introduced gently through nasal route into the trachea hearing patient's breath sound, fixed after confirming the position by capnography and chest auscultation [Figure 4]. General anesthesia was maintained with propofol, tramadol, atracurium and sevoflurane. Surgeon proceeded with surgery uneventfully. Mass was resected through cervical approach. Trachea was successfully extubated and post-operative period was uneventful.
Figure 4: After nasal intubation

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   Discussion Top

The art of blind oral and nasal intubation is gradually losing its importance, though it is safe alternative technique to tackle difficult airway. The availability of versatile and highly innovative equipments, make the most difficult airway situation easily approachable. Unfortunately, these sophisticated equipments may not be available in all institutions. Nasotracheal route is chosen when oral route is not accessible due either to limited mouth opening, difficulty in ventilation through face mask or would impede surgical access. Despite the fiberoptic bronchoscope is available in our institute, during those days it was not working properly and we had to plan either blind nasal intubation or awake retrograde intubation.

Blind nasal intubation was used in patients breathing spontaneously under deep inhaled anesthesia, but it can be performed smoothly in awake patients under topical anesthesia, as well.

We chose awake blind nasal intubation in our study, the advantages of which was shown by Moustafa et al. in their study comparing fiberoptic and blind nasotracheal intubation in awake surgical patient. They found no significant difference between groups with a success rate of 80% in blind nasal and 73.3% in fiberoptic intubation and concluded that awake blind nasal intubation could be an alternative safe method for anticipated difficult airway. [6] It might also be an alternate technique where fiberoptic is not available or failed to pass through glottis due to blood or massive secretion. Blind nasal intubation is a technique learned only by practice and nothing but psychomotor skill with low complication rate. [7],[8]

In another study, Danzl and Thomas reported a success rate of 92% in emergency room requiring nasal intubation. However, there are certain difficulties which may be encountered during blind intubation like impregnation of ETT in the sulcus between the base of the tongue and epiglottis or on the anterior commissure of the glottic opening. [8]

Time taken for blind nasal intubation was 32.4 s with single attempt in our study. However, the mean time taken for blind nasal intubation as shown by Van Elstraete et al. was less (20.8 ± 23 s vs. 60.1 ± 56 s) in comparison to fiberoptic nasal intubation. [9] Saha et al. in their study also reported time duration of 81 ± 63 s for fiberoptic nasal intubation with mean attempts of 1.06 ± 0.08 in awake patients with cervical spine disease. [10]

Complications associated with nasotracheal intubation are nosebleeds resulting from trauma to nasal or pharyngeal mucosa caused by rigid tip or sharp edged Murphey eye of ETT or trauma to the turbinates. To reduce the risk of trauma we used vasoconstrictor and also identified the patency of the nostrils. Enk et al. also dilated the identified nostril by inserting a Wendl tube temporarily and found reduced incidence and severity of bleeding and decreased post-operative nasal pain. [11]

Potdar et al. in a series of case reports on intraoral swelling showed that the tracheal intubation was facilitated by direct laryngoscopy by left molar approach after induction of general anaesthesia. [12] We never took the risk of general anesthesia compromising the airway; rather awake nasotracheal intubation was planned and successfully accomplished as an alternative to fiberoptic nasal intubation.

Thus, it can be concluded that difficult airway situation can be well managed, even in the absence of advanced equipments like fiberoptic bronchoscope, with this technique of awake blind nasal intubation; thus substantiating the fact that this age-old technique is still valuable and all anesthesiologists should gain expertise in it so as to overcome situations of difficult airway.

   References Top

1.Krishna R, Wali M, Nataraj MS, Shenoy T. Mallampatti class 4 to class 1!! J Anaesthesiol Clin Pharmacol 2012;28:264-5.  Back to cited text no. 1
2.Fischer SP, Bader AM, Sweitzer B. Preoperative evaluation. In: Miller RD, editor. Miller′s Anaesthesia. 7 th ed.: Elsevier, Churchill Livingstone; 2010. p. 1007.  Back to cited text no. 2
3.Naithani M, Jain A. Failed nasal intubation after successful flexible bronchoscopy: Guide wire to the rescue. J Anaesthesiol Clin Pharmacol 2011;27:395-7.  Back to cited text no. 3
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4.Henderson J. Airway managemeny in adult. In: Miller RD, editor. Miller′s Anaesthesia. 7 th ed.: Elsevier, Churchill Livingstone; 2010. p. 1579.  Back to cited text no. 4
5.Mulroy MF. Airway. In: Mulroy MF, editor. A Practical Approach to Regional Anesthesia. 4 th ed.: Lippincott Williams and Wilkins; 2009. p. 267-9.  Back to cited text no. 5
6.Moustafa AM, Nassef MA, Azim KA. Comparison between fibreoptic and blind nasotracheal intubation criteria in awake surgical patients. Alexandria J Anaesth Intensive Care 2005;8:17-23.  Back to cited text no. 6
7.Lee JA, Atkinson RS. A Synopsis of Anaesthesia. 7 th ed. Bristol: John Wright and Sons Ltd., 1973.  Back to cited text no. 7
8.Danzl DF, Thomas DM. Nasotracheal intubations in the emergency department. Crit Care Med 1980;8:677-82.  Back to cited text no. 8
9.Van Elstraete AC, Mamie JC, Mehdaoui H. Nasotracheal intubation in patients with immobilized cervical spine: A comparison of tracheal tube cuff inflation and fiberoptic bronchoscopy. Anesth Analg 1998;87:400-2.  Back to cited text no. 9
10.Saha AK, Higgins M, Walker G, Badr A, Berman L. Comparison of awake endotracheal intubation in patients with cervical spine disease: The lighted intubating stylet versus the fiberoptic bronchoscope. Anesth Analg 1998;87:477-9.  Back to cited text no. 10
11.Enk D, Palmes AM, Van Aken H, Westphal M. Nasotracheal intubation: A simple and effective technique to reduce nasopharyngeal trauma and tube contamination. Anesth Analg 2002;95:1432-6.  Back to cited text no. 11
12.Potdar M, Patel RD, Dewoolkar LV. Molar intubation for intra oral swellings: our experience. Indian J Anaesth 2008;52:861-5.  Back to cited text no. 12
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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