To the Editor:-Dr. Larson described pressure in the "laryngospasm notch," the depression just posterior to the condyle of the mandible, as the best treatment of laryngospasm. [1] He has had 40 yr of success with this treatment but is unsure why it works. I agree with his clinical observations and offer some additional thoughts from 28 yr of successfully using and teaching the technique.

Pushing in the postcondylar notch applies pressure to the styloid process, a bony spicule on the base of the skull. Bending the styloid process creates intense periosteal pain, which disappears as soon as the pressure is released. This pain is easily felt by pushing on one's own styloid process. Having residents locate this site in themselves quickly teaches how to find it in patients. Dr. Larson advocates pressure at the most proximal site in the notch as most effective. I also have advocated this site after possibly fracturing a styloid process from too distal pressure early in my career.

Larson is able to hold a mask on the face of a patient with his thumbs and first fingers while pushing behind each mandibular condyle with his middle fingers. Although I occasionally use this technique, many practitioners find it difficult. Another technique, which I prefer and find easier to teach, is to hold the anesthesia mask with my left hand and apply pressure in the postcondylar notch with my right. This unilateral technique usually permits a good mask seal and the build-up of positive airway pressure when the pop-off valve is closed while relieving the laryngospasm. If bilateral postcondylar pressure is needed, I usually have an assistant hold the face mask.

Intense stimulation caused by postcondylar pressure can be observed in a lightly anesthetized patient breathing without airway obstruction. Pressure in such a patient usually causes a sigh, and if the anesthesia is very light, a facial grimace. Postcondylar pressure can thus also help determine the depth of anesthesia during emergence.

Robert E. Johnstone, M.D.

Professor and Chair; Department of Anesthesiology; West Virginia University; Morgantown, West Virginia 26506;

(Accepted for publication March 18, 1999.)


Larson CP: Laryngospasm-The best treatment. Anesthesiology 1998; 89:1293-4