Discussion retromolar space and the efficacy of retromolar

 Discussion :               Mandible is the most common siteof injury in children because of it’s a) location (nasal bone and mandible arethe most prominent part of the face in children). b) Changing ratio of cranialvolume and facial volume from 8:1 to 2.5 :1. c) Direction of the growth of themandible i.

e downwards and forwards with increasing age.               Airway management in facialtrauma defend the use of oroendotracheal intubation because it does not givesthe flexibility of assessing the occlusion and maxillomandibular fixation whichis are prime requisite in reduction and fixation of facial fractures. Thusconventionally the practice was of using tracheostomy or nasoendotrachealintubation for administering anaesthesia . Though nasoendotracheal intubationis a preferred modality in adults but  inpediatric facial fractures it increases the risk of bleeding  due to hypertrophied adenoids. Techniques likesubmental intubation and tracheostomy are also used but the complications with these techniques can be avoided withretromolar intubation specifically in pediatric maxillofacial trauma patients.

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                           The prime objective of the studywas to assess the adequacy of the retromolar space and  the efficacy of retromolar intubation inpediatric mandibular fractures without compromising the anaesthetic as well assurgical requirements. Primary requirement for successful placement ofendotracheal tube in retromolar region is adequacy of space. In this report,the adequacy of space wasevaluated by placing nasopharyngeal airway in retromolar region which created amemory path for insertion of endotracheal tube while the patient wasunconscious as described by LT Nguyen et al.8          With the absence of third molars inpatients aged less than 14 years, the availability of retromolar space adds inanother dimension to the intubation technique. Patients intubated with theendotracheal tube in retromolar space have a reliable airway, greatervisibility and unobstructed surgical access to the nose and oral cavity.

Intraand postoperative complications are relatively low when compared to otherintubation techniques and without compromising the patency of the patientsairway make retromolar intubation a choice of intubation in pediatric patients.9            Accidentalextubation or dislodgement could be a challenging and discomforting situationfor both anesthetist and surgeon. In the present study, there was no episode ofaccidental dislodgement of ETT, because ETT was safely and easily placed in theretromolar space, finally positioned there with the help of 3-0 silk suture.                The retromolar intubation can not beused in patients with craniofacial syndromes like Pierre Robin syndrome,Treacher Collin syndrome, Achondroplasia and mandibular hypoplasia mostlybecause there is a lack of co-operation in these patients for procedure. Thoughit is needed more studies in future amongst every patient with maxillofacialtrauma along with pediatric patients, it is a safer and non-invasive technique.5                  In conclusion, retromolar regionused for endotracheal intubation provided adequate  space in pediatric patients. As it is notinfluenced by eruption of permanent first and second molars. Here, it is possible to achieve the occlusionwith placement of endotracheal tube in retromolar space.

Thus, it is having agreat hold on less complication strategies this technique can be used forintubation where intraoperative maxillomandibular fixation and access to noseand oral cavity is needed.