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CASE REPORT
Year : 2009  |  Volume : 53  |  Issue : 2  |  Page : 230-232 Table of Contents     

Fiberoptic Intubation Using LMATM as A Conduit and Cook® Airway Catheter as An Exchanger in A Case of Tessier 7 Facial Cleft Syndrome


1 Head of the Department, Department of Anaesthesia, Jaslok Hospital and Reserch Center, Mumbai, India
2 DNB student, Department of Anaesthesia, Jaslok Hospital and Reserch Center, Mumbai, India
3 Consultant Anaesthetist , Department of Anaesthesia, Jaslok Hospital and Reserch Center, Mumbai, India

Date of Web Publication3-Mar-2010

Correspondence Address:
Anand Jain
601, Luv Apartments, Veera Desai Road, Andheri West, Mumbai-400053
India
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Source of Support: None, Conflict of Interest: None


PMID: 20640130

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Any anaesthesiologist handling a paediatric airway must have a detailed understanding of the differences in airway anatomy, signs and symptoms of airway compromise and common paediatric airway abnormalities. In addition to various equipments needed to manage a difficult airway, there should be a clear plan for evaluation, preparation and management of life threatening complications. We share our experience of successfully managing a difficult airway of a 5 year old child with Tessier 7 facial cleft syndrome. We emphasize the importance of preoperative evaluation, preparation and use of various airway adjuncts.

Keywords: Tessier syndrome, Macrostomia, LMA TM , Fiberoptic bronchoscope, Cook® airway catheter


How to cite this article:
Dasgupta D, Jain A, Baxi V, Parab A, Budhakar A. Fiberoptic Intubation Using LMATM as A Conduit and Cook® Airway Catheter as An Exchanger in A Case of Tessier 7 Facial Cleft Syndrome. Indian J Anaesth 2009;53:230-2

How to cite this URL:
Dasgupta D, Jain A, Baxi V, Parab A, Budhakar A. Fiberoptic Intubation Using LMATM as A Conduit and Cook® Airway Catheter as An Exchanger in A Case of Tessier 7 Facial Cleft Syndrome. Indian J Anaesth [serial online] 2009 [cited 2020 Jul 12];53:230-2. Available from: http://www.ijaweb.org/text.asp?2009/53/2/230/60285


   Introduction Top


In 1976, Tessier proposed an anatomic classifi­cation of rare facial, craniofacial, and laterofacial clefts. In this classification, the orbit is used as the primary structure of reference. Fifteen locations for clefts can be differentiated. The classification facilitates an under­standing of tridimensional structure of these deformi­ties. [1] The etiology of these clefts is an embryonic de­velopmental failure of structures derived from 1st& 2nd branchial arches resulting in maxillary, mandibular and aural hypoplasia. The clinical expression of Tessier 7 ranges from a preauricular skin tag to a cleft across the cheek from angle of the mouth to the ear. When the cleft is bilateral, it leads to gross macrostomia. [1]


   Case Report Top


A 5-year-old male child, known case of bilateral Tessier 7 facial cleft syndrome, was posted for total correction of facial deformity. He was a preterm child delivered vaginally. Presence of gross macrostomia at birth precluded breastfeeding. Till the age of 3 months, he was fed through a nasogastric tube after which a feeding gastrostomy was done under general anaes­thesia, details of which were not available. Feeding gastrostomy was closed at the age of 2 years under GA, the details of which are not known. The child was on liquids and semi solid food since then.Before the surgery at our Hospital, he was kept NBM for 6 hours. There were no other associated congenital deformi­ties. Milestones were normal. A history of snoring and repeated upper respiratory tract infections was present. On general examination, height was 95cm and weight was 15kg with a low set of ears. Airway examination revealed a facial cleft extending from angle of the mouth across the cheek to the ear on both sides amounting to gross macrostomia [Figure 1]& [Figure 2]. Mouth opening was 3cm [Figure 1] Showing lateral view, Mallampatti classifi­cation-IV and thyromental distance-2.5cm with severe retrognathia. Teeth were severely maloccluded. Neck movements and other systems were normal. Routine investigations were normal. Preoperatively, the child was kept fasting for 6 hrs. Venous access was taken in the ward. No sedative premedication was administered in the ward due to history of snoring. In the operation theater, a difficult airway cart including fiberoptic bron­choscope and tracheostomy kit was kept ready. Moni­toring included a precordial stethoscope, electrocar­diogram, pulse oximeter, non invasive blood pressure cuff, capnogram and temperature probe. Plan of intu­bation was to secure a non surgical airway in an anaesthetised patient. Awake fiberoptic intubation was not possible since it would require a quite cooperative child for good bronchoscopic views. Our PLAN A was to attempt a direct laryngoscopy after sevoflurane in­duction. PLAN B was to do LMA TM guided fiberoptic intubation. For preoxygenation, we had to use a No 5 face mask due to the gross macrostomia. Gamgee pads were applied around the mask to reduce the leak and improve the seal. Injection glycopyrrolate 0.06 mg was administered and the child was anaesthetised with sevoflurane. Direct laryngoscopy revealed Cormack Lehane IV. Since it was becoming increasingly difficult to maintain the airway with mask, we decided to intro­duce an LMA TM size 2 ½. After confirming adequate ventilation with the LMATM, fentanyl 30 mcg, propofol 30 mg, atracurium 10 mg were given intravenously.

Then, through the LMA TM , fiberoptic bronchscope with a 5mm safety flex tube mounted on it was introduced. The tube was then passed across the cords to secure the airway.

Although the child was being ventilated adequately, the LMA TM had to be removed as it would hinder the oral surgery. Hence, we decided to remove the LMATM­tube assembly over a Cook® airway exchange catheter [Figure 3]. Finally, the same 5mm safety flex tube was then railroaded back over Cook® catheter and ven­tilation was confirmed with EtCO2. We have used two uncuffed tubes of the same size without the connectors.The distal tip of the upper tube including the Murphy eye was cut away and then the cut end was plugged into the enlarged cavity of the proximal end of the lower tube to form a stable tube of double length. The tube was then fixed in midline with surgical sutures and the throat was packed. Surgery was un­eventful. Post operatively the child was shifted to Pae­diatric ICU on ventilator.


   Discussion Top


Children with Tessier 7 syndrome often prove to be difficult candidates for airway management. Huge macrostomia leads to a difficult mask fit, while intuba­tion can be very challenging. Always anticipate difficult airway and choose an appropriate technique. 2 Direct laryngoscopy can either be difficult or impossible. Mul­tiple attempts cause edema and bleeding with subse­quent difficult ventilation. [Figure 2] Front view showing mouth opening, [Figure 4] X ray skull lateral view showing malocclusion of teeth). Hence an alternative technique to secure the airway without traumatizing the larynx should be sought. In our patient, following direct laryn­goscopy, we were unable to visualize even the epiglottis. So we went to our plan B, which was LMA TM guided fiberoptic intubation. [3] Performing an awake fiberoptic intubation in paediatric population is challenging, if not impossible. For intubation through LMA TM , both blind as well as fiberoptic techniques are described. How­ever, blind methods should be avoided due to the risk of trauma and bleeding. LMA TM guided fiberoptic intuba­tion has gained popularity as the LMA TM provides a patent airway, a conduit for the bronchoscope and control ven­tilation at the same time. [4],[5] If the LMA TM does not inter­fere with the surgery, it can be left in place. However the greatest challenge encountered when intubating through an LMA TM is its removal without dislodging the endotra­cheal tube. This difficulty is unique to paediatric airway as the lengths of an age appropriate endotracheal tube and LMA TM are similar. The proximal end of the tube tends to disappear into the LMA TM once the tube has passed through the vocal cords. [6] Various methods have been described to circumvent this problem. Most com­monly, this is done by removing the tube connector and attaching another similar sized tube proximally to the first tube. [7] Peter et al [8] have described the use of LMA TM guided fiberoptic intubation and Cook® airway exchange catheter in difficult paediatric airway. The advantages of this catheter are long length, atraumatic, continuous ac­cess to airway and ability to oxygenate and ventilate during exchange process.

Walburn et al [9] have used a guidewire for the ex­change of LMATM-tube assembly in a difficult paediat­ric case. However, the guidewire proves to be too soft and thin for support. Use of gum elastic bougie, adult stylets and ureteral dilators have also been described. [10] One must always anticipate, prepare and plan for a difficult paediatric airway. Various airway adjuncts should be used judiciously. LMA TM guided fiberoptic intubation has become gold standard for difficult pae­diatric airway. Cook® airway catheter should be used as an exchanger in difficult airway as it has distinct ad­vantage over other adjuncts.



 
   References Top

1.Tessier P. Anatomical classification of facial, craniofacial and laterofacial clefts. J Maxillofac Surg 1976; 4 :69-92.  Back to cited text no. 1  [PUBMED]    
2.Benumof JL. The laryngeal mask airway and The ASA difficult airway algorithm. Anesthesiology 1996; 84: 689-699.  Back to cited text no. 2      
3.John M, Berger TM. Fiberoptic intubation through the laryngeal mask airway (LMA) as a standardized proce­dure. Pediatr Anesth 2004; 14 :614-15.  Back to cited text no. 3      
4.Yang YS, Son CS. Laryngeal mask airway guided fibreoptic tracheal intubation in a child with a lingual thyroglossal duct cyst. Paediatr Anaesth 2003; 13: 829-831.  Back to cited text no. 4      
5.Walker RWM, Aklen DL, Rothera MR. A fibreoptic intu­bation technique for children with mucopolysaccharidoses using the laryngeal mask air­way. Paed Anesth 1997; 7: 421-426.  Back to cited text no. 5      
6.Inada T, Fujise K, Tachibana K, Shingu K. Orotracheal intubation through the laryngeal mask airway in paedi­atric patients with Treacher-Collins syndrome. Paediatr Anaesth 1995;5:129-32.  Back to cited text no. 6  [PUBMED]    
7.Markus Weiss, Andreas C. Gerber, Achim Schmitz. Con­tinuous ventilation technique for laryngeal mask air­way (LMATM) removal after fiberoptic intubation in children. Pediatric Anesthesia 2004;14:936-940.  Back to cited text no. 7      
8.Peter B. Thomas , Martin G. Parry.The difficult paediat­ric airway: a new method of intubation using the laryn­geal mask airway™, Cook® airway exchange catheter and tracheal intubation fibrescope. Pediatric Anesthe­sia. 2001;11:618-621.  Back to cited text no. 8      
9.Walburn MB, Cornes J, Ryder IG. Fiberoptic intubation through a laryngeal mask airway facilitated by a guide wire. Anaesthesia 2000; 55 : 1027-28.  Back to cited text no. 9      
10.Rajan GR. Fiberoptic wire guided transoral and through the LMA intubation technique using modified gum elas­tic bougie. Anesthesia& Analgesia 2005; 101: 1880-94.  Back to cited text no. 10      


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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