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Glossopharyngeal nerve blocks for awake laryngeal mask insertion in infants: are they necessary?

SIR—We read with interest the article by Jagannathan et al. entitled ‘Glossopharyngeal nerve blocks for awake laryngeal mask airway insertion in an infant with Pierre-Robin syndrome: can a Glidescope come to the rescue?’, in which the authors describe performing glossopharyngeal nerve blocks in an infant (1). The authors are to be commended for describing another technique to facilitate airway management in these patients. While this technique for performing glossopharyngeal nerve blocks may be useful in some patients, the available literature suggests that it is unnecessary for this application in infants <2 months old. In their description of awake insertion of the laryngeal mask in five infants with either the Robin sequence or Treacher Collins syndrome, Asai et al. state ‘our patients tolerated the presence of the mask and finger in the mouth without topical anesthesia’ and ‘it appeared they became calm’ (2). In the first description of this technique by Markakis et al. in three infants with micrognathia, the level of distress associated with awake laryngeal mask insertion is described as comparable to that seen with orogastric or nasogastric tube insertion in the awake child. The authors point out that this level of distress did not prevent a smooth inhaled induction of anesthesia (3). In our own review of this technique in 14 infants with the Robin sequence, we found no mention of intolerance of awake laryngeal mask insertion; furthermore, there were no episodes of oxyhemoglobin desaturation prior to or during induction of anesthesia in any of these infants, suggesting satisfactory tolerance (4). Glossopharyngeal nerve injections carry the risks of local anesthetic toxicity and may result in bleeding that can interfere with subsequent intubation attempts. It is quite likely that the level of stimulation caused by positioning the glidescope is comparable to that associated with laryngeal mask placement. We therefore suggest that these nerve blocks be reserved for infants who fail an initial attempt at awake placement of the laryngeal mask. P A U L A. S T R I C K E R J O H N E. F I A D J O E The Children’s Hospital of Philadelphia Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania School of Medicine Philadelphia, PA, USA (email: strickerp@email.chop.edu) References