Flexible laryngeal mask airway for symblepharon surgery with oral mucous membrane grafting: A feasible option

Dear Editor, Symblepharon is defined as adhesions between the palpebral and bulbar conjunctiva due to burns, conjunctival chronic inflammatory diseases, trauma, and infections. The surgical management of symblepharon includes symblepharon release and tissue grafting to the affected areas. The autograft can be taken from the conjunctival, oral, or nasal mucosa.[1] In literature, oral and nasal mucosal grafts have been obtained under general anesthesia with an oral/nasal endotracheal tube and a throat pack.[2] We performed this in 10 such cases with flexible laryngeal mask airway (LMA) and oral packing to absorb any blood. All patients were administered general anesthesia with inhalational or intravenous induction method, and airway was secured with flexible LMA. The air tube of flexible LMA was taped at the corner of the mouth instead of the center of the lower lip as an oral mucosal graft from the lip was taken [Figure 1]. An oral pack was placed in the oral cavity and positioned precisely between the tongue and the hard palate. Submucosal lignocaine 2% with adrenaline 1:200,000 was injected in the graft-harvesting site of the mucosal surface of the lower lip to reduce bleeding before the start of the procedure. At the end of the surgery, the oral pack was removed and the upper airway was suctioned for any trickled blood from the graft excision. Flexible LMA was removed once the patient achieved adequate breathing and airway reflexes. In the post-anesthesia care unit, no active bleeding was seen from the oral donor graft site in any patient. The surgeon did not face any difficulty during graft harvesting and surgery.Figure 1: Airway secured with flexible LMA for eye surgery requiring oral mucous membrane graft. The LMA is fixed toward the left side of the cheek. LMA = laryngeal mask airwayOral mucous membrane grafts offer numerous advantages, including comparable biological properties to the conjunctiva, technical simplicity, accessibility, avoidance of risks associated with allogenic grafts, and the feasibility of repeat harvesting. Laryngoscopy and intubation have been associated with tachycardia, hypertension, and increased intraocular pressure. Supraglottic airway devices (SGAs) are preferred for ophthalmological procedures to prevent laryngoscopy, intubation, and extubation response.[3] SGA has been used for syringing and probing, dacryocystorhinostomy, and tonsillectomies successfully without airway complications.[4,5] Till now, surgeries involving harvesting of oral mucous membrane grafts had been managed by securing the airway via an endotracheal tube with a throat pack. However, we have succes sfully performed these surgeries using a flexible LMA with no signs of aspiration in any case, as the graft was taken from the lower lip and an oral pack was placed carefully in the oral cavity, positioned between the tongue and the hard palate, using submucosal lignocaine 2% with adrenaline 1:200,000 at the graft site and cautery to achieve minimal bleeding. Our technique not only provided adequate exposure for the graft harvested from the lower lip, but also provided enough space for the performance of surgery as it can be fixed away from the surgical field due to the flexible air tube. Therefore, we suggest that flexible LMA is a viable alternative to endotracheal tubes with throat pack for symblepharon release requiring oral mucous membrane grafting. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.