Perioperative Airway Management in Treacher Collins Syndrome With Obstructive Sleep Apnea: A Case Report

BACKGROUND Treacher Collins syndrome (TCS) is a congenital disorder resulting from maldevelopment of the first and second pharyngeal arches. A major high-risk comorbidity is obstructive sleep apnea (OSA), characterized by recurrent upper airway collapse during sleep, leading to intermittent hypoxia and sleep fragmentation. This condition requires a tailored anesthetic strategy due to an anticipated difficult airway during intubation and increased vulnerability to postoperative respiratory failure. CASE REPORT A 28-year-old man with TCS and polysomnography-confirmed mild OSA underwent orthognathic surgery. Preoperative evaluation included cone-beam computed tomography (CBCT), which objectively quantified retrolingual airway stenosis. After a multidisciplinary briefing, anesthesia was induced with intravenous remimazolam, propofol, sufentanil, and cisatracurium; the airway was secured through videolaryngoscopy-guided nasotracheal intubation. This technique optimized glottic visualization, and controlled induction was feasible because mask ventilation difficulty was not anticipated. The surgical procedure (Le Fort I osteotomy, bilateral sagittal split osteotomy, and genioplasty) was performed to expand the upper airway and correct skeletal deformities. Comparisons of preoperative and postoperative CBCT images and lateral cephalometric radiographs demonstrated clear upper airway expansion and improvement in airway obstruction. Postoperative anesthetic management prioritized a strict opioid-sparing analgesic protocol and monitored extubation, resulting in an uneventful recovery. CONCLUSIONS Management of patients with TCS and OSA during orthognathic surgery relies on a proactive, imaging-informed approach. Key elements include the use of advanced imaging for precise anatomic risk stratification, selection of an intubation technique that provides definitive airway visualization, and implementation of a structured multidisciplinary plan with vigilant postoperative monitoring to mitigate delayed respiratory complications.