Bhogal, H. S. MD, FFARCSI; Gan, T. J. MBBS, FRCA
Department of Anesthesiology Duke University Medical Center Durham, NC 27710
Difficult airway in a hospital setting is not uncommon but, when one meets an emergency situation complicated by an unknown custom, the results can be embarrassing, at least, and perhaps a disaster. Fairley and O’Riordan (1) described a case in which a difficult endotracheal intubation was encountered in a Sikh in an elective setting; they recommend a routine airway assessment must be performed in patients who have a beard. However, in a situation when a formal airway assessment may not be possible, such as during an emergency, familiarity with the Sikhs’ custom may be life saving. A young Sikh was found unconscious on the roadside and brought to our emergency department. The team followed the advanced cardiac life support algorithm and found that the patient had noisy respiration. An attempt was made to clear the mouth, but they could not open it. The patient was unresponsive to verbal commands. After several futile attempts to overcome airway obstruction and with worsening oxygen desaturation, an emergency tracheotomy was performed and adequate ventilation was established. After the procedure, it was found that a firm cord, hidden within the beard, had prevented the mouth from opening.
When they strictly adhere to religious belief, the Sikhs, in adult life, have beards that are unshorn, uncut, or not trimmed. To keep the beard manageable, various methods are used. These include tying the hair into a knot and concealing it under the beard; pleating the beard from top to bottom; tying a knot and concealing the knot; and using hair-fixing preparations to fix the beard. Another method is to take a firm cord, place it behind the angle of the jaw, and tie it very securely and tightly over the top of the head. The hair of the beard is then combed back with a metal rod or pin toward the cord, and the length is curled behind the cord in a sweeping manner until the beard is neatly tucked away behind the cord (Figs. 1 and 2). The cord on the top may disappear in the hair on the head or under the turban, which the Sikhs wear when outside. The Sikhs who use this method are usually restricted in swallowing big boluses of food. Mouth opening is severely restricted in the presence of an applied cord.
When encountering difficult mouth opening in Sikh patients, it is prudent to check the presence of the cord for restraining the beard. The cord should then be cut or loosened by untying the slipknot.
H. S. Bhogal MD, FFARCSI
T. J. Gan MBBS, FRCA
