AIR-17
A Case Series of Unique Airway Management in Patients with Micrognathia
Battles R, Mehta S
University of Florida, Gainesville, Florida, United states
Introduction
Micrognathia is defined as mandibular hypoplasia. From mask ventilation to intubation, micrognathia can present a daunting challenge in airway management for anesthesiologists. Proposed methods include oral airways, laryngeal mask airways, video laryngoscopy, fiberoptic scope, and surgical airway manipulation. Below are cases when these methods alone proved inefficient.
Case Presentation
Case 1 is a 4-week-old male with a past medical history of dysmorphia including frontal bossing, micrognathia, ventricular septal defect, and coarctation of the aorta presenting for Nissen fundoplication and gastrostomy tube placement. Our plan of video laryngoscopy was unsuccessful. We were successful with intubation through a laryngeal mask airway using a fiberoptic scope.
Case 2 is a 2-month-old male with a past medical history of uncontrolled seizures with apneic episodes associated with GLUT-1 deficiency and micrognathia presenting for surgical intubation after failed attempt at bedside. The surgical plan of rigid laryngoscopy alone was unsuccessful. We successfully intubated only after concurrent use of video laryngoscope, rigid laryngoscope, and cricoid pressure.
Case 3 is a 2-month-old female with Pierre Robin sequence complicated by severe sleep apnea and micrognathia who presented for bilateral mandibular osteotomies and internal distractor placement. Nasal intubation with fiberoptic scope alone proved unsuccessful. It required jaw thrust, tongue retraction, and oral intubation with a rigid laryngoscope with surgeons. We then performed concurrent video laryngoscope and nasal fiber optic scope to exchange the oral tube for a nasal tube.
Discussion
Airway management in these patients required multiple attempts, interdisciplinary teams, and combined advanced airway techniques. Oral airways proved life saving in our cases where airway management took an hour or more. Because of the high risk of surgical airway or failed airway, we consulted airway surgeons to be present in the operating room to assist. They assisted us with a unique technique of suturing the tongue to the bottom lip prior to surgical instrumentation due to tongue base prolapse. LMAs nicely facilitated the fiberoptic scope into the airway. Once placed, removal of LMAs posed an additional obstacle. We had difficulty with the standard practice of “railroading†two endotracheal tubes together and used our fiberoptic scope to hook the LMA and mechanically remove the LMA while still visualizing ETT positioning. We present these cases with the purpose of fostering continued discussion and research into standardized, safe, and time-efficient airway management methods in patients with micrognathia.
References
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2. Jarrahy R. Controversies in the management of neonatal micrognathia: to distract or not to distract, that is the question. J Craniofac Surg. 2012;23:243–249. doi: 10.1097/SCS.0b013e318241b90a.
3. Buchanan EP; Hollier LH. Syndromes with craniofacial abnormalities. Weisman LE; Firth HV; Elizabeth T, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on November 7, 2017.)
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