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The inability to extend the head may be due to a blocked cervical spine or to any cervical instability imposing to maintain the head straight. Exposure of the glottis during intubation may be difficult and can be ameliorated by a stable general anesthesia, some pressure on the larynx and by charging the epiglottis. When mouth aperture is superior to 40 mm, a lighted stylet, a laryngoscope with a prism, a fiberoptic laryngoscope (Bullard) or the PCV laryngoscope represent a possible alternative to the Mac Intosh laryngoscope. If mouth aperture is superior to 20 mm but inferior to 40 mm, a ENT or PCV laryngoscope or a fiberoptic intubation are recommended. One should remember that the intubation is easier if the diameter of the ET tube is small. If the mouth aperture is inferior to 20 mm, nasal intubation (if intubation is indicated) is mandatory using fiberoptic intubation or a retrograde technique or even nasal blind intubation. In case of failure of intubation in a hypoxic patient, the anterior percutaneous route should always be kept in mind and transtracheal ventilation should be ready in case of failure, or even tracheotomy.

The PCV (Piquet-Crinquette-Vilette) laryngoscope has been designed for use in difficult endotracheal intubation in the adult. Its blade, 170 mm long, is curved, narrow (12 mm internal diameter) and semicircular in cross-section, like a closed C. An 8 mm endotracheal tube can be pushed through this blade. There is a cold light source. The use of this blade requires a teeth protector. The epiglottis will be lifted directly, and the blade will be moved into the vestibule, stopping short of the vocal cords. The endotracheal tube will then be introduced into the laryngoscope blade which guides it in between the cords. Once the tube has been checked to be within the trachea, the laryngoscope is removed by sliding the blade backwards over the tube. The PCV may be introduced into the mouth either on the right, or on the left, or behind the molar teeth, or between two teeth. It can held with the handle horizontal in case of a prominent sternum. The limits of this tool are a mouth opening of less then 20 mm, and some rare predictable difficulties which require an X-ray assessment to determine the best intubation technique to be used. Of 115 patients with a predicted difficult endotracheal intubation, fifty were intubated with the PCV without any failures. Also, twenty-five patients, out of thirty, were successfully intubated with the PCV after an attempt with a MacIntosh blade had failed. Of these five failures, one was never intubated by any technique whatsoever, two were intubated by fibroscopy and two by the ENT surgeon.

Carinal resection and reconstruction via a right transpleural approach in an hypoxemic patient provides difficult maintenance of satisfactory gas exchange when one lung ventilation is inadequate. The present case report concerns a 62-year-old patient with chronic obstructive airways disease and a carinal squamous cell carcinoma. He underwent tracheobronchial reconstruction surgery by Barclay's procedure through a right postero-lateral thoracotomy. During resection and reconstruction phases, the gas exchange was maintained by a new technic: high-frequency-jet-ventilation (HFJV) with two small-bore catheters through the endotracheal tube and JVHF ventilators adjusted to the compliance of each lung (high for the right lung, low for the left one). No circulatory changes were observed during the sutures lines phase (90'). The oximeter and the arterial blood gas values show an adequate procedure. The immediate post operative period was unremarkable and uncomplicated. The histological diagnosis was squamous cell carcinoma involving the carina with one metastatic pretracheal lymph node and microscopic infiltration of the left main bronchus resection margin. Sixteen grays postoperative radiotherapy was required. Ten months after the patient is alive, without tumor recurrence. HFJV greatly facilitates surgery by avoiding endobronchial intubation with large cuffed tubes into the surgical field. In patients with low pulmonary reserve, bilateral lung HFJV is required: two JVHF ventilators with different ranges delivering separate ventilation to the right and left lungs avoid left hypoventilation and right surgical emphysema and insure good surgical conditions.

The authors report their experience with 210 microsurgical ethmoidectomies carried out in 109 patients between 1980 and 1987. In 23 patients the anatomy was considerably modified due to previous surgery. Asthma was present in 56 patients and 25 patients suffered from Widal's syndrome. The complications noted included 1 case of meningitis cured by antibiotics and a case of transient diplopia. Patients were monitored for 1 to 6 years; In 69 cases no recurrence was noted (63% of cases), 31 patients (28%) only required minor local procedures for slight recurrence (28%). On the other hand, 6 patients (5.5%) required a second surgical procedure for recurrence between 3 and 6 years.