[Downloaded free from http://www.ijaweb.org on Thursday, June 10, 2021, IP: 253.240.72.

164]

Letters to Editor

a b

Figure 2:  (a) Diagrammatic representation of looping of cuff‑inflating channel around the posterior border of the turbinate.  (b) Winding the
cuff‑inflating channel around the tracheal tube ensures the movement occurs en masse

Conflicts of interest Clin Pharmacol 2011;27:141‑2.

There are no conflicts of interest.
Sheeba J Annie, R Sripriya, Areti Archana,
T Sivashanmugam
Department of Anaesthesiology and Critical Care, Mahatma Gandhi
Medical College and Research Institute, Puducherry, India
Address for correspondence:
Dr. R Sripriya,
Department of Anaesthesiology, Mahatma Gandhi Medical College
and Research Institute, Pillayarkuppam, Puducherry ‑ 607 402, India.
E‑mail: docsripriya@gmail.com
REFERENCES
5. Smith JE, Reid AP. Asymptomatic intranasal abnormalities
influencing the choice of nostril for nasotracheal intubation.
Br J Anaesth 1999;83:882‑6.
6. Ahmed‑Nusrath A, Tong JL, Smith JE. Pathways through the
nose for nasal intubation: A comparison of three endotracheal
tubes. Br J Anaesth 2008;100:269-74.
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
Access this article online
Quick response code
Website:
www.ijaweb.org

1. Davila VR, Schwab C, Papadimos TJ, Casabianca AB.

A difficult extubation: Endotracheal tube ensnarement by a
Kirschner wire. Int J Crit Illn Inj Sci 2015;5:128‑9.
2. Dryden GE. Circulatory collapse after pneumonectomy (an
unusual complication from the use of a Carlens catheter): Case
report. Anesth Analg 1977;56:451‑2.
3. Suresh YV, Mehandale SG, Vijesh KS. Difficult extubation – A
case report. Indian J Anaesth 2004;48:307‑8.
4. Suman S, Ganjoo P, Tandon MS. Difficult extubation due to
failure of an endotracheal tube cuff deflation. J Anaesthesiol
DOI:
10.4103/ija.IJA_275_17
How to cite this article: Annie SJ, Sripriya R, Archana A,
Sivashanmugam T. Yet another cause for difficult extubation of
nasotracheal tube. Indian J Anaesth 2017;61:684-5.
© 2017 Indian Journal of Anaesthesia | Published by Wolters Kluwer - Medknow

Encountering caudal cyst on Morphological/anatomical variations in the

ultrasound: What do we do?
Sir,
Caudal block is one of the most commonly performed
regional anaesthesia techniques in paediatric patients
for umbilical or subumbilical procedures. Commonly,
the caudal block is performed with traditional
landmark technique. Accidental dural punctures
and trauma to the base of the sacrum are some of the
known complications of this technique.
lumbosacral region such as sacral meningocele,
meningeal diverticulum, extradural cysts and
perineural cysts[1‑3] are usually asymptomatic in
neonates and infants. They can be associated with
skin discolouration of the sacral area, sacral dimple or
hair tuft. Ultrasound scanning in such cases helps us
pick up the pathology and gives us clear idea of what
we are dealing with.
Our patient was a 17‑month‑old male child
(weight 7.6 kg) posted for hypospadias repair. He was a
pre‑mature child born at 28 weeks and was a Neonatal
Intensive Care Unit graduate of around 6 weeks. His

Indian Journal of Anaesthesia | Volume 61 | Issue 8 | August 2017 685

Page no. 83
[Downloaded free from http://www.ijaweb.org on Thursday, June 10, 2021, IP: 253.240.72.164]
Letters to Editor
routine haematological and biochemical workup was
normal.
On the day of surgery, standard nil per os guidelines
was followed. The child was pre‑medicated with
0.75 mg/kg midazolam with sugar orally 20 min
pre‑operatively. Our anaesthesia plan was to maintain
spontaneous ventilation with the face mask[4] and
ultrasonography (USG)‑guided caudal block.[5] The
pros and cons of caudal block were discussed with
parents as per our routine.
Anaesthesia induction was started with O2, N2O and
sevoflurane. Intravenous access was established with
22‑gauge intravenous (I.V.) cannula. I.V. glycopyrrolate
(4 μg/kg) was administered. The patient was turned
left lateral for caudal block. The sacral area of the
patient had discolouration and a discreet dimple
noted on table as shown in Figure 1a. USG scanning
of the sacral area revealed an anechoic cystic structure
amidst the hyperechoic strands of filum terminale as
shown in Figure 2a and b. Caudal block was given
with 22‑gauge spinal needle (Quincke type) 30 mm
length under real‑time USG guidance [Figure 1b]
avoiding the cyst as shown in Figure 2c. A volume
of 3.5 ml of local anaesthetic mixture (0.5 ml 2%
lignocaine with 1:200,000 adrenaline and 3 ml of
0.25% bupivacaine) was used for caudal block. There
was no response to surgical stimulus. Duration of
surgery was 1.5 h. Anaesthesia was maintained with
O2, N2O and sevoflurane 1% through face mask.[4] At
the end of surgery, the child was shifted to recovery
room. Post‑operative analgesia was maintained with
syrup ibuprofen 38 mg orally thrice daily.
In our case, the cyst was clearly picked up by USG
screening and the caudal block was safely performed
by negotiating needle in accordance to the real‑time
scan, avoiding the cyst. With increasing availability
and increasing expertise of USG equipment, it is
highly recommended anaesthesiologists should use
a b
Figure 1: (a) Sacral area of patient with discolouration and discrete
dimple. (b) Ultrasound‑guided caudal block
686
Page no. 84
USG regularly for performing caudal block, especially
in the presence of signs suggesting anomalies.
Visible anatomical variations are tell‑tale signs of
abnormalities such as the dural sac terminating
abnormally low.[1,2] Any obviously visible anatomical
variation such as tuft of hair, a dimple in the caudal
area are often considered as a relative contraindication
for caudal block. Routine use of ultrasound could aid
us in converting these relative contraindications into
safely doable techniques. Cystic structures, including
the cerebrospinal fluid (CSF), may go unnoticed.
These scenarios could increase the chances of dural
punctures or inadvertent deposition of the local
anaesthetic dose calculated for caudal epidural into
the CSF leading disastrous complications.
This makes a reasonable case for routine use of USG
guidance for caudal blocks, and especially, when the
telltale sign of an underlying anomaly is apparent,
before abandoning the procedure.
Acknowledgement
The authors would like to thank Dr. Kiran A. Puranik
MD.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Vrushali Chandrashekhar Ponde1,2,
Vinit Vinod Bedekar1,2
1
Children’s Anaesthesia Services, 2Department of Anaesthesiology,
Surya Children’s Hospital, Mumbai, Maharashtra, India
a b
c
Figure 2:  (a and b) Ultrasonography scanning of the sacral area
showing an anechoic cystic structure amidst the hyperechoic strands
of filum terminale. (c) Real‑time ultrasonography scan of sacral area
showing needle avoiding the cyst
Indian Journal of Anaesthesia | Volume 61 | Issue 8 | August 2017
[Downloaded free from http://www.ijaweb.org on Thursday, June 10, 2021, IP: 253.240.72.164]
Letters to Editor
Address for correspondence:
Dr. Vinit Vinod Bedekar,
Building No. B‑41/201, Yogi Nagar, Yogi Saraswati CHS, Eksar
Road, Borivali West, Mumbai ‑ 400 091, Maharashtra, India.
E‑mail: dr.vinitbedekar@gmail.com
REFERENCES
1. Kim SG, Yang JY, Kim DW, Lee YJ. Inadvertent dural puncture
during caudal approach by the introducer needle for epidural
adhesiolysis caused by anatomical variation. Korean J Pain
2013;26:203‑6.
2. Joo J, Kim J, Lee J. The prevalence of anatomical variations that
can cause inadvertent dural puncture when performing caudal
block in Koreans: A study using magnetic resonance imaging.
Anaesthesia 2010;65:23‑6.
3. North RB, Kidd DH, Wang H. Occult, bilateral anterior sacral
and intrasacral meningeal and perineurial cysts: Case report
and review of the literature. Neurosurgery 1990;27:981‑6.
4. Ponde V. Surgical mask used as a harness. Paediatr Anaesth
2006;16:601.
5. Ponde VC. Recent developments in paediatric neuraxial
blocks. Indian J Anaesth 2012;56:470‑8.
A novel position for D2
kyphoplasty: Swimmer’s position
Sir,
Kyphoplasty for benign osteoporotic fractures
is mainly carried out under local anaesthesia.
Kyphoplasty for malignant lesions (multiple myeloma)
or spinal metastases from primary tumours elsewhere
in the body (breast, prostate), often requires prone
positioning under general anaesthesia using an
armoured or flexometallic tube.[1] These kyphoplasties
are performed under portable C‑arm/fluoroscopic
guidance in the operation room. The two upper limbs
are generally kept 90° abducted at the shoulder joint
and 90° flexed at the elbow joint, the forearms lying
parallel to the long axis of the pronated head. The
forehead and chin rest against elevations on the head
rest while supports are placed under the iliac crests
and upper thorax.[2] Care is taken to keep the eyeballs
and abdomen free from contact with the operation
table. All lumbar and almost all thoracic vertebrae
lesions can be subjected to needle implantation and
bone cement injection in this standard position.
However, while imaging T1 and T2 lesions using the
C‑arm, with patient in standard position, the shoulder
mass obstructs the view of lower cervical and first
two thoracic vertebrae making surgery impossible.
To overcome this predicament, we devised a special
modified prone position, the ‘Swimmer’s position’
Indian Journal of Anaesthesia | Volume 61 | Issue 8 | August 2017
Page no. 85
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
Access this article online
Quick response code
Website:
www.ijaweb.org
DOI:
10.4103/ija.IJA_144_17
How to cite this article: Ponde VC, Bedekar VV. Encountering
caudal cyst on ultrasound: What do we do?. Indian J Anaesth
2017;61:685-7.
© 2017 Indian Journal of Anaesthesia | Published by Wolters Kluwer - Medknow
inspired by the cervicothoracic Swimmer’s view
X‑ray (SVXR) for lateral projection in cervical spine
X‑rays.[3]
The most common cervical projections in routine
use in the radiology suite are the anteroposterior and
lateral. Special projections such as the ‘swimmer’s
view’ may be employed for better demonstration of C‑7
and T‑1 to T‑3 vertebrae, which on the standard lateral
projection are obscured by the overlying clavicle and
shoulder girdle soft tissues. The patient stands with his
coronal plane perpendicular to the X‑ray plate, raises
one arm, lowering opposite shoulder and rotating
both shoulders away from midline.[3,4] The shoulder
mass is moved aside, revealing the lower cervical,
T1 and T2 vertebrae. Swimmer’s View X Ray (SVXR)
is a complicated X‑ray for both the radiographers
and patient because of complex patient positioning.
The shoulders may have limited flexibility and
particularly in trauma patients, pulling or adjusting
the arms may worsen any cervical spine injury.
SVXR has largely been replaced with newer imaging
modalities such as computed tomography (CT)
scan and magnetic resonance imaging (MRI) in the
radiology suite.[3] However, for D2 lesions being
operated under fluoroscopic guidance, this position is
a boon since CT and MRI imaging are not available
as point‑of‑care facilities for the intraoperative period
unlike the C‑arm. Under general anaesthesia, there is
a real risk of traction nerve injury in patients operated
in the prone position. We obtained our Swimmer’s
position with the patient prone [Figure 1] and not
687