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LETTER TO EDITOR
Year : 2016  |  Volume : 60  |  Issue : 11  |  Page : 868-869  

Overcoming airway challenges with the C-MAC® video laryngoscope in a child with Goldenhar syndrome


Department of Anaesthesiology and Critical Care, School of Medical Sciences, Universiti Sains Malaysia Health Campus, Kelantan, Malaysia

Date of Web Publication9-Nov-2016

Correspondence Address:
Wan Fadzlina Wan Muhd Shukeri
Department of Anaesthesiology and Critical Care, School of Medical Sciences, Universiti Sains Malaysia Health Campus, Kelantan
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.193704

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How to cite this article:
Shukeri WF, Zaini RH, Soon CE, Hassan MH. Overcoming airway challenges with the C-MAC® video laryngoscope in a child with Goldenhar syndrome. Indian J Anaesth 2016;60:868-9

How to cite this URL:
Shukeri WF, Zaini RH, Soon CE, Hassan MH. Overcoming airway challenges with the C-MAC® video laryngoscope in a child with Goldenhar syndrome. Indian J Anaesth [serial online] 2016 [cited 2020 Nov 26];60:868-9. Available from: https://www.ijaweb.org/text.asp?2016/60/11/868/193704

Sir,

Goldenhar syndrome is a rare congenital disorder that is characterised by a wide range of anomalies including of the face and neck. [1] From the anaesthesiologist's perspective, the anticipation of the difficult airway is of the highest importance in patients with this syndrome. [1] The C-MAC® video laryngoscope system (Karl Storz GmbH and Co. KG, Tuttlingen, Germany) is an airway tool that comes with interchangeable laryngoscope blades (Miller size 0 and size 1, Macintosh size 2) for adult and paediatric use. [2] Evidence for its use is mainly from adult studies [3],[4] and children with normal airways. [5] We wish to highlight the difficulties we faced in securing a difficult airway in a child with Goldenhar syndrome using the C-MAC system and how we overcame them.

A 3-year-old, 8.5 kg girl with Goldenhar syndrome was scheduled for revision of the right eye coloboma repair and palatoplasty. During the pre-anaesthesia evaluation, her airway examination revealed micrognathia, mandibular hypoplasia, limited mouth opening and reduced neck mobility. From previous anaesthetic records, it was noted that she had two episodes of failed intubations before due to anteriorly placed vocal cords (with Cormack-Lehane [C-L] Grade IV) under conventional direct laryngoscopy.

In view of anticipated difficult intubation, we intended to use asleep fiberoptic intubation. However, paediatric-sized fibreoptic bronchoscope was not available at that time. Instead, we planned to use the C-MAC video laryngoscope as the first option. Our first laryngoscopy attempt after gas induction using C-MAC/Miller size 1 blade revealed a C-L Grade IIIb view. We changed to C-MAC/Macintosh size 2 blade in the second attempt, but similar view was obtained. The bulky handle of the C-MAC system abutted the patient's chest preventing full insertion of the blade and this was overcome by placement of a shoulder roll. In the meantime, a senior anaesthesiologist was called for help.

The senior anaesthesiologist attempted laryngoscopy with C-MAC/Miller size 1, again C-L Grade IIIb was obtained, but this time, blind intubation was attempted. However, it resulted in an oesophageal intubation. In the fourth attempt, using the same blade, with concurrent external laryngeal manipulation and more shoulder elevation, CL IIIa view could be obtained. A bougie was inserted towards the location of the glottic opening, with successful intubation.

Our case demonstrated that the C-MAC system is useful in providing a better grade of C and L view of glottis when difficult intubation is encountered in a paediatric patient by virtue of its ability provide a better glottic view, with improvement in CL view from grade IV without the C-MAC to grade III with the aid of the device. However, one cannot rely solely on the use of paediatric C-MAC system in difficult airway cases and need to employ a combination of effective manoeuvres for a successful intubation. Repeat laryngoscopic attempts can be risky and earlier anticipation and additional manoeuvres can result in successful intubation, with lesser number of attempts. It is worth noting that the relatively bulky handle of the device may interfere with the intubation process by abutting the patient's chest thus preventing full insertion of the blade. This limitation may be overcome by placement of a shoulder roll which helps to reduce the angulation problem.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Onal O, Kutahya EC, Arun O, Duman A. Our anesthesia experience in a patient with Goldenhar-Gorlin syndrome. J Anesth Crit Care Open Access 2015;2:65.  Back to cited text no. 1
    
2.
Oakes ND, Dawar A, Murphy PC. Difficulties using the C-MAC paediatric videolaryngoscope. Anaesthesia 2013;68:653-4.  Back to cited text no. 2
    
3.
Cavus E, Thee C, Moeller T, Kieckhaefer J, Doerges V, Wagner K. A randomised, controlled crossover comparison of the C-MAC videolaryngoscope with direct laryngoscopy in 150 patients during routine induction of anaesthesia. BMC Anesthesiol 2011;11:6.  Back to cited text no. 3
    
4.
Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology 2012;116:629-36.  Back to cited text no. 4
    
5.
Mutlak H, Rolle U, Rosskopf W, Schalk R, Zacharowski K, Meininger D, et al. Comparison of the TruView infant EVO2 PCD™ and C-MAC video laryngoscopes with direct Macintosh laryngoscopy for routine tracheal intubation in infants with normal airways. Clinics (Sao Paulo) 2014;69:23-7.  Back to cited text no. 5
    



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