The patient should be assessed for anaesthesia in the standard manner. Non-consent, inability to comply with the anaesthetist's instructions as, for example, a result of deafness or mental incapacity, inability to lie¯at, allergy to local anaesthetics, lack of i.v. access, or excessive uncontrollable anxiety are absolute contraindications to Sub-Tenon's anaesthesia. The procedure should be explained to the patient to allay anxiety and assist the anaesthetist in carrying out the block.
We report a case of total upper airway obstruction occurring immediately after extubation after elective bi-maxillary osteotomy. The obstruction was caused by severe, progressive supraglottic oedema, which totally obscured the laryngeal inlet. No swelling had been present at initial laryngoscopy and intubation. Immediate re-intubation of the patient's trachea was difficult but life saving. Subsequent investigations revealed extensive soft tissue swelling, maximal at the level of the hyoid and extending downwards into the trachea. The cause of such severe oedema in this case is not certain, but may be related to vigorous submental liposuction carried out at the end of operation. We have found no other reports of total airway obstruction occurring immediately after extubation as a result of this cause. We review the appropriate literature, describe the postoperative management and suggest precautions in similar patients.
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