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Education  |   March 2013
Beware the Horns of the Mandible!
Author Notes
  • Department of Anesthesiology, Albany Medical Center, Albany, New York.
Article Information
Education / Airway Management / Gastrointestinal and Hepatic Systems / Ophthalmologic Anesthesia / Respiratory System / Technology / Equipment / Monitoring
Education   |   March 2013
Beware the Horns of the Mandible!
Anesthesiology 3 2013, Vol.118, 710. doi:10.1097/ALN.0b013e31826b70b0
Anesthesiology 3 2013, Vol.118, 710. doi:10.1097/ALN.0b013e31826b70b0
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A MALE, 66 yr old, with hypertension presented for excision of left eye pterygium. On routine exam and assessment of his airway, he was noted to have massive tori mandibularis, or bony exostoses of the mandible. The case proceeded uneventfully under light sedation and local anesthetic infiltration by the ophthalmologist. The patient was discharged home after completion of the procedure.
Tori mandibularis are unilateral or bilateral exostoses that occur on the lingual surface of the mandible. Prevalence estimates range between 0.5–7% of the general population, with higher rates in Alaskan Eskimos and Eastern Aleuts (61%).1 Most of these exostoses are benign, and treatment is not routinely recommended.
Difficult intubation has been reported in these patients.2 Because of the tori, there may be no room to compress the tongue and soft tissue of the mandibular space, which hampers visualization of the glottis. Although flexible fiberoptic intubation remains the gold standard in airway management, rigid video laryngoscopy is met with variable success.3 Anatomically shaped rigid laryngoscopes, such as the Bullard and its modern derivatives, may facilitate intubation, although data are scant to recommend a specific device over another. Direct laryngoscopy with Macintosh and Miller blades has repeatedly proven unsuccessful. Preanesthetic exam of the sublingual space may avoid unanticipated airway management difficulty.
References
Woods GM. Mandibular tori as a cause of inability to visualize the larynx. Anesth Analg. 1995;81:870–1
Durrani MA, Barwise JA. Difficult endotracheal intubation associated with torus mandibularis. Anesth Analg. 2000;90:757–9
Yoshida H, Sawada M, Takada N, Kushikata T, Hirota K. Rigid videolaryngoscope for difficult intubation caused by mandibular tori. J Anesth. 2011;25:473–4
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