Anaesthesia for Treacher Collins syndrome using a laryngeal mask airway

Anesthetic Management of Treacher Collins Syndrome in an Outpatient Surgical Center

Patient: Male, 15-year-old

Final Diagnosis: Treacher Collins syndrome

Symptoms: Difficult airway management

Medication:—

Clinical Procedure: —

Specialty: Anesthesiology

Difficult fiberoptic tracheal intubation in 1 month-old infant with Treacher Collins Syndrome

Case report

Conclusion

[Difficult fiberoptic tracheal intubation in 1 month-old infant with Treacher Collins Syndrome]

Neonates and small infants with craniofacial malformation may be very difficult or impossible to mask ventilate or intubate. We would like to report the fiberoptic intubation of a small infant with Treacher Collins Syndrome using the technique described by Ellis et al.

CASE REPORT

An one month-old infant with Treacher Collins Syndrome was scheduled for mandibular surgery under general endotracheal anesthesia. Direct laryngoscopy for oral intubation failed to reveal the glottis. Fiberoptic intubation using nasal approach and using oral approach through a 1.5 size laryngeal mask airway were performed; however, both approach failed because the fiberscope loaded with a one 3.5mm ID uncuffed tube was stuck inside the nasal cavity or inside the laryngeal mask airway respectively. Therefore, the laryngeal mask airway was keep in place and the fiberoptic intubation technique described by Ellis et al. was planned: the tracheal tube with the 15mm adapter removed was loaded proximally over the fiberscope; the fiberscope was advanced under video-screen visualization into the trachea; the laryngeal mask airway was removed, leaving the fiberscope in place; the tracheal tube was passed completely through the laryngeal mask airway and advanced down over the fiberscope into the trachea; the fiberscope was removed and the 15mm adapter was reattached to the tracheal tube.

CONCLUSION

The fiberoptic intubation method through a laryngeal mask airway described by Ellis et al. can be successfully used in small infants with Treacher Collins Syndrome.

Small is the new big: An overview of newer supraglottic airways for children

Almost all supraglottic airways (SGAs) are now available in pediatric sizes. The availability of these smaller sizes, especially in the last five years has brought a marked change in the whole approach to airway management in children. SGAs are now used for laparoscopic surgeries, head and neck surgeries, remote anesthesia; and for ventilation during resuscitation. A large number of reports have described the use of SGAs in difficult airway situations, either as a primary or a rescue airway. Despite this expanded usage, there remains little evidence to support its usage in prolonged surgeries and in the intensive care unit. This article presents an overview of the current options available, suitability of one over the other and reviews the published data relating to each device. In this review, the author also addresses some of the general concerns regarding the use of SGAs and explores newer roles of their use in children.

Comparison of oral fiberoptic intubation via a modified guedel airway or a laryngeal mask airway in infants and children

BACKGROUND

Though fiberoptic intubation (FOI) is considered the gold standard for securing a difficult airway in a child, it may be technically difficult in an anesthetized child. The hypothesis for this study was that it would be easier to perform FOI via a laryngeal mask airway (LMA) than a modified oropharyngeal airway with the advantage of maintaining anesthesia and oxygenation during the process.

MATERIALS AND METHODS

30 children aged 6 months to 5 years undergoing elective surgery under general anesthesia were randomized to two groups to have fiberoptic bronchoscope (FOB) guided intubation either via a modified Guedel airway (FOB-ORAL) or a classic LMA (FOB-LMA). In the FOB-LMA group, the LMA was removed when a second smaller endotracheal tube was anchored to the proximal end of the tracheal tube in place.

RESULTS

Oral fiberoptic intubation was successful in all children. The first attempt success rate was 11/15 (73.33%) in the FOB-LMA group and 3/15 (20%) in the FOB-ORAL group (P = 0.012). Subsequent attempts at intubation were successful after 90° anticlockwise rotation of the endotracheal tube over the FOB. The time taken for fiberoptic bronchoscopy was significantly less in FOB-LMA group (59.20 ± 42.85 sec vs 108.66 ± 52.43 sec). The incidence of desaturation was higher in the FOB-ORAL group (6/15 vs 0/15).

CONCLUSION

In children, fiberoptic bronchoscopy and intubation via an LMA has the advantage of being easier, with shorter intubation time and continuous oxygenation and ventilation throughout the procedure. Removal of the LMA following intubation requires particular care.

Anesthesia for Treacher Collins syndrome: a review of airway management in 240 pediatric cases

OBJECTIVES

To review airway management with anesthesia for children with Treacher Collins syndrome (TCS) and determine whether intubation was more difficult with increasing age.

BACKGROUND

Treacher Collins syndrome is a rare disorder of craniofacial development characterized by maxillary, zygomatic, and mandibular dysplasia. TCS is associated with difficult intubation, but reports of airway management are limited to case reports and small cases series. Children with TCS may require multiple general anesthetics, and it has been suggested that intubation becomes more difficult with increasing age.

METHODS

A retrospective case note review of children with TCS from birth to 18 years undergoing anesthesia from 1971 to 2011 in a single center was performed. Demographic data, procedure type, anesthesia type, method of airway management, modified Cormack-Lehane (MCL) grade of laryngoscopic view, and any other descriptions of airway difficulty or complications were collated.

RESULTS

Of 59 patients with TCS, 35 children underwent a total of 240 anesthetics, most commonly for craniofacial surgery. Final airway management consisted of face mask 17%, laryngeal mask airway 16%, endotracheal intubation 49%, and 18% had a preexisting tracheostomy. The laryngeal mask airway provided an adequate airway in all cases when it was used. MCL grade was recorded in 97 cases involving 28 patients: 7% grade 1, 9% grade 2a, 31% grade 2b, 26% grade 3, and 27% grade 4. Fifteen (54%) patients were MCL grade 4 on at least one occasion. Failed intubation occurred in 6 (5%) of 123 cases of planned intubation. The procedure was canceled in two cases (0.8%) because of failure to intubate. Intubation techniques other than conventional direct laryngoscopy were used in 41% of cases. MCL grade increased with increasing age (P = 0.007).

CONCLUSIONS

Most children with TCS have difficult laryngoscopic views with many requiring specialized intubation techniques. Direct laryngoscopy becomes more difficult with increasing age. The laryngeal mask airway is a good choice of airway when endotracheal intubation is not required.

Evaluation of air-Q™ intubating laryngeal airway as a conduit for tracheal intubation in infants--a pilot study

BACKGROUND

Air-Q™ intubating laryngeal airway (ILA) has been used successfully as a conduit for tracheal intubation in pediatric difficult airway. However, its use as an airway device and conduit for intubation in infants is not yet evaluated.

AIMS

The primary objective was to evaluate ILA as a conduit for tracheal intubation in infants, and secondary objectives were to evaluate ILA in terms of ease of insertion and ventilation, oropharyngeal leak pressure (OLP), glottic view, and complications.

METHODS

Twenty infants with normal airway were included. After induction of general anesthesia and neuromuscular blockade, ILA (size 1.0/1.5) was inserted. Fiberoptic bronchoscope (FOB)-guided intubation and removal of ILA with the stabilizing stylet was attempted.

RESULTS

The mean age and weight of the infants were 7.5 ± 2.3 months and 7.3 ± 1.8 kg. The ILA sizes 1.0 and 1.5 were inserted in 10 infants each according to the weight of the infants. The mean OLP was 18.5 ± 1.8 cm H₂O, and mean time for insertion of ILA was 13.3 ± 3.9 s. Glottic view was grade I in 6, grade II in 1, grade III in 4, and grade IV in nine infants. Tracheal intubation was successful in 19/20 infants. The mean endotracheal tube (ETT) insertion time and mean total time (ILA insertion to the confirmation of ETT placement) were 95.6 ± 32.3 s and 306.42 ± 120.2 s respectively.

CONCLUSION

The ILA is a safe and easy-to-use supraglottic airway device for intubation with FOB in infants with normal airway. Insertion and removal of ILA are easy with satisfactory oropharyngeal seal and ventilation.

[Use of a metal guide in the working channel of a fiberoptic scope to insert a tracheal tube in an infant with Treacher Collins syndrome and choanal atresia]

Neonates with Treacher Collins syndrome can present difficult airways. Ventilation through a face mask and laryngoscopy for tracheal intubation may prove impossible due to the craniofacial malformations that are characteristic of this syndrome. Furthermore, patients with this syndrome are at high risk of airway obstruction, meaning that awake fiberoptic endoscopy provides the best option for tracheal intubation. This technique is especially difficult in children, however, and material required for performing it in neonates is not always available. We report the case of a 5-day-old infant boy with Treacher Collins syndrome and bilateral choanal atresia in whom we used a flexible metal guide inserted into the working channel of a fiberoptic scope. The tracheal tube could then be inserted.

The new air-Q intubating laryngeal airway for tracheal intubation in children with anticipated difficult airway: a case series

The air-Q intubating laryngeal airway (ILA) is a new supraglottic airway device which may overcome some limitations inherent to the classic laryngeal mask airway for tracheal intubation. We present a case series of patients with anticipated difficult airway in whom the air-Q ILA was successfully used as a conduit for fiberoptic intubation.

Airway management in a patient with Goldenhar syndrome: a case report

Children with Goldenhar syndrome are known to present airway management challenges for the anesthesiologist. We present the case of a 10-year-old child with Goldenhar syndrome, in whom a flexible Laryngeal Mask Airway (Intavent Orthofix, Ltd, Maidenhead, UK) was successfully used for eye surgery.

The Use of Three-Dimensional Computed Tomography Images for Anticipated Difficult Intubation Airway Evaluation of a Patient with Treacher Collins Syndrome

A 13-year-old girl with Treacher Collins syndrome who had a history of difficult intubation was scheduled for plastic surgery. We took three-dimensional computed tomography images to better evaluate the anatomical features of the upper airway. The patient's anesthetic airway management was influenced by the findings of the images.

[Anesthetic management of pediatric cleft lip and cleft palate repair]

We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate. The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.

Fiberoptic Tracheal Intubation Through a Laryngeal Mask Airway in a Child with Treacher Collins Syndrome

Treacher Collins syndrome (TCS) is a rare inherited condition characterized by bilateral and symmetric abnormalities of structures within the first and second bronchial arches. The mechanism of inheritance is autosomal dominant with variable expressivity. Because of this variability in expression, some affected individuals exhibit virtually no overt clinical manifestations. However, most children with TCS present with the following classic facial features: down-sloping palpebral fissures, colobomata of the lower eyelid, scanty lower eyelashes, malar hypoplasia, and micro- or retrognathia. Cleft palate is present in up to 35% of patients and an additional 30-40% have congenital palatopharyngeal incompetence. Abnormalities of the ear are very common and vary from minor malformations to severe microtia and hearing loss. Hearing loss may be due to atresia of the auditory canals or ossicular malformation of the middle ear. Despite these many development abnormalities, TCS patients are usually of normal intelligence. We report the case of a 3 1/2-yr-old patient with TCS undergoing cleft palate repair and discuss fiberoptic intubation through a laryngeal mask airway using two endotracheal (ETT) tubes secured via an ETT connector.

[Laryngeal mask airway in paediatrics: when? How?]

Since its introduction in 1981 by Brain, the laryngeal mask airway has achieved increased popularity in pediatrics. Despite widespread use, the definitive role of the laryngeal mask airway has yet to be established. We attempt to clarify the role of the laryngeal mask airway in airway management during anaesthesia by discussing the advantages and disadvantages as well as the indications and contra-indications of its use. The use in failed or suspected difficult endotracheal intubation was also described. Finally, we review the techniques of insertion, details of misplacement, the removal and complication associated with the use of laryngeal mask airway. Cleaning, pre-use checking and maintenance were also discussed.

Treacher Collins syndrome: current evaluation, treatment, and future directions

OBJECTIVE

Treacher Collins syndrome (TCS) is an inherited disorder in which there are general bilateral symmetric anomalies of the structures within the first and second branchial arches. In general, there is complete penetrance and variable expressivity of the trait. The craniofacial rehabilitation of a child with TCS is tailored to the extent of the deformities involved: the orbitozygomatic region, the maxillomandibular region, the nose, facial soft tissues, and external and middle ear structures.

CONCLUSION

This article reviews the range of clinical features and specific dysmorphology observed in TCS. Functional and aesthetic objectives are discussed, and a comprehensive staged reconstructive approach is outlined, which may be used as a roadmap for treatment planning.

Treacher Collins Syndrome: Current Evaluation, Treatment, and Future Directions

Objective

Treacher Collins syndrome (TCS) is an inherited disorder in which there are bilateral symmetric anomalies of the structures within the first and second branchial arches. In general, there is complete penetrance and variable expressivity of the trait. The craniofacial rehabilitation of a child with TCS is tailored to the extent of the deformities involved: the orbitozygomatic region, the maxillomandibular region, the nose, facial soft tissues, and external and middle ear structures.

Conclusion

This article reviews the range of clinical features and specific dysmorphology observed in TCS. Functional and aesthetic objectives are discussed, and a comprehensive staged reconstructive approach is outlined, which may be used as a roadmap for treatment planning.

The laryngeal mask airway in the difficult paediatric airway: an assessment of positioning and use in fibreoptic intubation

The laryngeal mask airway (LMA) was used in 34 children who presented with difficult airways and difficulty in intubation. All 34 children were a grade 3 or grade 4 Cormack and Leehane view at conventional laryngoscopy. The laryngeal mask airway was used as part of the anaesthetic technique. It was either used as the method of airway maintenance during a short procedure or as an aid to fibreoptic intubation. The results of its use in this group of patients showed that overall a good airway was obtained in 73% of patients and an adequate airway in 27%, and in no patient was a poor airway obtained. The fibreoptic positioning of the LMA, taken from the distal aperture of the laryngeal mask airway showed that, overall, in 29.5% of patients a full view of the glottis (grade 1) was obtained, in 29.5% of patients a partial view of the glottis (grade 2) was obtained and in 41% a view of the epiglottis only (grade 3) was obtained. In no patient was a view excluding the epiglottis obtained. In children with a mucopolysaccharide disorder, the number of children who had a grade 3 view increased to 54%. Children with a disorder other than mucopolysaccharidosis had a grade 3 view in only 17% of cases. Children with mucopolysaccharidoses had a grade 1 view in only 14% of cases compared with 58% in the group with other disorders. Of the 34 patients, 21 patients were intubated on 31 separate occasions. There were no failures. The complications of the fibreoptic intubation technique described are outlined.

Anesthesia for Freeman-Sheldon syndrome using a laryngeal mask airway

PURPOSE

To present a case of Freeman-Sheldon syndrome (FSS) with a previously unreported technique of anesthetic management, consisting of a malignant hyperthermia free anesthetic and laryngeal mask airway.

CLINICAL FEATURES

Freeman-Sheldon syndrome (also known as whistling face syndrome, Windmill-Vane-Hand syndrome, cranio-carpo-tarsal dysplasia and distal arthrogryposis type 2) is a rare congenital disorder defined by facial and skeletal abnormalities. The three basic abnormalities are microstomia with pouting lips, camptodactyly with ulnar deviation of the fingers and talipes equinovarus. Patients with FSS frequently present for surgical correction of musculoskeletal or facial abnormalities. There are several anesthetic challenges including difficult airway, intravenous cannulation and regional technique. They may be at increased risk for malignant hyperthermia and postoperative pulmonary complications. We present a case of a two-year-old child with FSS undergoing elective unilateral inguinal hernia repair. A non-triggering anesthetic technique was used, consisting of 2 mg x kg(-1) propofol followed by a continuous infusion, nitrous oxide 50%/oxygen, and 3 microg x kg(-1) fentanyl. Intraoperative and postoperative analgesia was provided by an ilioinguinal nerve block with 10 ml bupivacaine 0.25% with epinephrine 1:200,000. The airway was maintained with a #2 laryngeal mask airway. The anesthetic was uneventful and there were no signs or symptoms of malignant hyperthermia. The patient was discharged home later the same day in good health.

CONCLUSION

The use of a laryngeal mask airway and non-triggering anesthetic technique should be considered as options for anesthetic management in patients with FSS for short procedures that do not require neuromuscular blockade.

A new technique for fibreoptic intubation in children

We describe a technique involving the use of a laryngeal mask airway, fibreoptic bronchoscope and a guide wire to manage the intubation of a child who was known to be a difficult intubation. The technique is simple, atraumatic, permits the use of an adult bronchoscope for infants and children, and allows control of the airway and ventilation throughout the period of intubation.

The laryngeal mask airway: its features, effects and role

The laryngeal mask airway was designed as a new concept in airway management and has been gaining a firm position in anaesthetic practice. Numerous articles and letters about the device have been published in the last decade, but few large controlled trials have been performed. Despite widespread use, the definitive role of the laryngeal mask has yet to be established. In some situations, such as after failed tracheal intubation or in anaesthesia for patients undergoing laparoscopic or oral surgery, its use is controversial. There are a number of unresolved issues, for example the effect of the laryngeal mask on regurgitation and whether or not cricoid pressure prevents placement of the mask. We review the techniques of insertion, details of misplacement, and complications associated with the use of the laryngeal mask. We discuss the features and physiological effects of the device, including the changes in intra-cuff pressure during anaesthesia and effects on blood pressure, heart rate and intra-ocular pressure. We then attempt to clarify the role of the laryngeal mask in airway management during anaesthesia, based on the current knowledge, by discussing the advantages and disadvantages as well as the indications and contraindications of its use. Lastly we describe the use of the laryngeal mask in circumstances other than airway maintenance during anaesthesia: fibreoptic bronchoscopy, tracheal intubation through the mask and its use in cardiopulmonary resuscitation.

Comparison of placement of the laryngeal mask airway with endotracheal tube by paramedics and respiratory therapists

STUDY OBJECTIVE

To determine the learning curve of nonphysician emergency personnel on placement of the laryngeal mask airway as compared to performance of endotracheal intubation.

DESIGN

Prospective, comparative, randomized, patient-blinded trial.

SETTING

Regional hospital operating room.

PARTICIPANTS

Seven experienced paramedics and 12 respiratory therapists trained in endotracheal intubation.

INTERVENTIONS

Patients used as subjects were anesthetized and paralyzed. Each participant then performed placement of both the laryngeal mask airway and endotracheal tube on the same patient in random sequence. Both techniques were observed for speed, difficulty, and effectiveness.

MEASUREMENTS AND MAIN RESULTS

The techniques were timed from the point at which the participant touched the patient to the time they were able to effectively ventilate the patient. Participants also were asked to rate the difficulty of each technique on a 100-mm visual analog score. Failure (three attempts without successful ventilation) rates also were monitored. The mean time to ventilate successfully with the laryngeal mask airway was significantly less than that with the endotracheal tube (38.9 +/- 1.9 seconds versus 206.1 +/- 31.9 seconds, P < .0001). The average number of attempts was 1.0 +/- 0.0 for the laryngeal mask airway and 2.22 +/- 0.21 for the endotracheal tube (P < .01). No one failed to place the laryngeal mask airway; and ten of 19 (52.6%, P < .01) failed to perform endotracheal intubation. The endotracheal tube had a significantly higher rating of difficulty than did the laryngeal mask airway (67.3 versus 8.64, P < .0001).

Use of the Augustine stylet anticipating difficult tracheal intubation in Treacher-Collins syndrome

Treacher-Collins syndrome is a familial and congenital condition often associated with a difficult airway. Although the condition is rare, the anesthesia care provider may encounter it on occasion. This report describes a patient with Treacher-Collins syndrome scheduled to undergo facial reconstruction (fore-head plasty, brow lift, and rhinoplasty) as the sixth of multiple operations. A nasotracheal intubation using the stylet component of a recently introduced airway device, the Augustine Guide, was successfully performed. This is believed to be the first reported use of this method using the Augustine stylet.

[Difficult intubation managed by laryngeal mask and fibroscopy]

A case is reported of a patient due to undergo a combined kidney and pancreas transplant who proved to be difficult to intubate. This diabetic hypertensive 35-year-old male patient also had ankylosing spondylitis. Mouth opening was normal (more than fingers' breadth), the chin-sternum distance was 4 cm on full cervical flexion, and cervical extension was only slightly impaired. The Mallampati score was 1. Anaesthesia was induced with thiopentone, fentanyl and 6 mg of pancuronium. Mask ventilation was quite satisfactory. However, on laryngoscopy, the vocal cords could not be seen. Several attempts to carry out endotracheal intubation, including with a stylet, failed. A laryngeal mask (LM) was therefore applied to ventilate the patient correctly. It was not possible to pass a small endotracheal tube (6 mm diameter) through the LM tube, probably because of a small malposition of this latter. A paediatric fibroscope, passed through the LM tube, served as guide for the endotracheal tube. The mask was not removed, although its cushion was slightly deflated, so as not to extubate the patient. The benefits and usefulness of a laryngeal mask in predictable and unpredictable cases of difficult intubation are discussed.