Correspondence 92 1

to hereditary or acquired C1 -inhibitor deficiency. The first of these appears unlikely as the swelling was localised. There were no other manifestations of histamine release and the patient was receiving steroids. The second is also unlikely as the swelling was unilateral, confined to the tongue and the patient had no previous history of swelling of extremities, face, neck or airway. C4 level measured pre-operatively was within the reference range.

Venous drainage of the tongue is via the lingual veins. All the veins from the same side converge posteriorly to drain into the lingual vein which passes medial to the greater cornu of the hyoid to join the internal jugular vein. Here it is a close relation to the lateral wall of the

oropharynx. We propose that the venous drainage of the left side of the tongue was obstructed in our patient by compression against the hyoid bone by the tracheal tube and throat pack. Furthermore, rotation of the neck may have exacerbated this by obstruction to the left sided neck veins.

New Cross Hospital, A.R. CLAXTON Wolverhampton J. PHILIPS

Reference [I] KANTOR G, FISHER J. Massive tongue swelling. Canadian

Journal of Anaesthesia 1992; 39 405-6.

Awake versus asleep fibreoptic intubation

I am gratified that renewed attention is being directed towards training in fibreoptic guided tracheal intubation in the UK and elsewhere. I note that Hartley et al. (Anaesthesia 1994; 49: 335-7) utilise a programme of teaching involving fibreoptic intubation under general anaesthesia, and they do mention possible complications of this method. They report the use of alfentanil to obtund the haemodynamic response to the technique.

The purpose of such a teaching programme is to prepare the anaesthetist to intubate the difficult airway. I contend that this is best achieved by learning awake fibreoptic techniques. Merely learning fibreoptic procedures in which the patient receives general anaesthesia ill prepares the trainee for the genuinely difficult case; these were actually excluded from the study. I concede that learning under general anaesthesia does allow the trainee to obtain some skills, such as fibrescope handling and tracheal tube advancement. But these are initial skills and there is much more to be learned.

A recent editorial in Anaesthesia agrees: ‘. . . None of the approaches under general anaesthesia permit the unhurried sequential identification of nasal, pharyngeal and laryngeal structures which is possible in the awake subject

and essential when patients with abnormal anatomy or pathology are subsequently encountered. In addition, neither of the techniques prepare the trainee adequately to perform an awake fibreoptic intubation in a patient with a difficult airway’ [I].

Safe and well tolerated methods are available for the teaching of fibreoptic intubation on awake patients [2, 31. These should be used to ensure satisfactory training. I am surprised that such methods have not gained widespread recognition in the UK, and I hope this will change in time.

Department of Anesthesiology, D.R. BALL UCI Medical Center, 101, City Drive South, PO Box 14091, Orange, California 92613-1491

References [ I ] MASON RA. Learning fibreoptic intubation: fundamental

problems. Anaesthesia 1992; 47: 729-31. [2] OVASSAPIAN A. Fiber optic airway endoscopy in anesthesia and

critical care. New York: Raven Press, 1990. [3] BENUMOF JL. Management of the difficult adult airway

with special emphasis on awake tracheal intubation. Anesthesiology 1991; 73: 1087-1 110.

Sterilisation of gum elastic bougies

The gum elastic bougie is an invaluable aid to intubation and has recently been advocated for use in intubating patients with unstable cervical spine injuries [I]. Many hospitals pay scant regard to the manufacturer’s recommen- dations [2] to sterilise the bougie chemically before storing them in a clean environment and avoiding exposure to light. Instead, it is common practice to decontaminate the bougie with soap and water and then to store them exposed to the atmosphere. In view of the theoretical risk of introducing micro-organisms into the lower bronchial tree of patients when using the bougie, the tips of the gum elastic bougies from various sites in a hospital were cultured. Microbial growth was obtained from all bougies sampled, with the heaviest growths being from the bougies used in the emer- gency operating theatre. This was presumably due to their greater use and handling at this location. The organisms cultured were environmental commensals. However, patho- genic organisms, such as Mycobacterium tuberculosis and

methicillin resistant Staphylococcus aureus, can reside in similar environments to that from which the organisms were isolated.

As a result of these findings and the desire to reduce the patients’ exposure to micro-organisms, which could poten- tially be pathogenic, gum elastic bougies are now sterilised chemically in this hospital, as recommended by the manu- facturers. Perhaps this policy should be instigated more widely?

Ormskirk District Hospital, M.J.R. LETHEREN Ormskirk, Lancs

References [ I ] NOLAN JP, WILSON ME. Orotracheal intubation in cervical

[2] Eschmann Healthcare. Tracheal tube introducer technical spine injuries. Anaesthesia 1993; 48: 630-3.

data sheet.