Difficult paediatric intubation when fibreoptic laryngoscopy fails

Area of Science:

• Pediatric Otolaryngology
• Medical Device Technology
• Genetics and Rare Diseases

Background:

• Negar syndrome, a rare condition resembling Treacher-Collins syndrome, presents with craniofacial abnormalities and conductive hearing loss.
• Previous surgical intervention for obstructive sleep apnea, specifically mandibular distraction, can alter upper airway anatomy.
• Difficult airway management is a known challenge in patients with craniofacial syndromes.

Observation:

• A significant challenge was encountered during fibreoptic bronchoscopy in an 8-year-old girl with Negar syndrome.
• Standard fibreoptic intubation attempts failed to visualize the glottis due to complex laryngeal distortion.
• The distortion was attributed to differential fibrosis following mandibular distraction surgery, causing triplanar laryngeal malposition.

Findings:

• Successful glottic visualization and tracheal intubation were achieved using a blind nasal intubation technique to guide the fibreoptic scope.
• The primary obstruction was a large epiglottis obscuring the distorted larynx.
• The older, breath-guided intubation technique proved effective in overcoming the anatomical challenges.

Implications:

• This case highlights the potential for surgical interventions in craniofacial syndromes to create unique airway challenges.
• It underscores the importance of considering iatrogenic anatomical changes when managing difficult airways.
• Breath-guided intubation should be considered as an alternative technique for fibreoptic bronchoscopy in complex pediatric airway cases.