Sir,Klippel–Feil syndrome, characterised by the triad of short neck, decreased cervical spine mobility and low posterior hairline, poses a challenge to the anaesthetist during airway management.[12] We describe the airway management in a patient with Klippel–Feil syndrome which required the interchange of airway management plan in two different surgical contexts.A 38-year-old female patient weighing 56 kg with Klippel–Feil syndrome [Figure 1] was scheduled for transoral odontoid process excision and occipitocervical fusion. Airway examination revealed limited cervical extension with modified Mallampati Class 2. The patient did not consent for awake fibre-optic bronchoscopic-guided intubation. Anaesthetic plan (Plan A) was orotracheal intubation following anaesthetic induction with or without the use of neuromuscular blocking drugs depending on the ease of mask ventilation, using Airtraq video laryngoscope with manual in-line stabilisation (MILS). Plan B was direct laryngoscopy with MILS using a stylet/bougie. Fibre-optic bronchoscope was kept ready in the operating room (Plan C).
Figure 1
Lateral view of neck X-ray of the patient showing fusion of the cervical vertebrae
Lateral view of neck X-ray of the patient showing fusion of the cervical vertebraeAfter initiating standard monitoring and securing intravenous (IV) access, anaesthesia was induced with IV fentanyl 75 μg and propofol 150 mg, and MILS was applied. Mask ventilation was easy, and neuromuscular blockade (NMB) was achieved with IV vecuronium. After 3 min of ventilation, an Airtraq with monitor (green blade) was used. However, no glottic structure was identifiable. Intubation through the Airtraq was abandoned. Anaesthesia was deepened, and direct laryngoscopy with size 3 Macintosh blade was performed with MILS (Plan B). A Grade 3 view was noted which improved to Grade 2b with optimal external laryngeal manipulation (OELM), and intubation was successful using stylet. Surgery (7 h) was uneventful. After discussion with neurosurgeons, trachea was extubated.After 16 h, she was posted for re-exploration to adjust the position of the screws. Since we had failed with the Airtraq during the previous anaesthetic, we decided to go ahead with direct laryngoscopy with MILS. Under similar anaesthesia, but using succinylcholine for NMB, direct laryngoscopy with size 3 Macintosh blade (Plan A) revealed Grade 4 view despite OELM. Two attempts to use gum elastic bougie failed. Mask ventilation was resumed. At this juncture, we decided to try the Airtraq once (Plan B). With Airtraq (green blade), Grade 2a view of the glottis was obtained. Tracheal intubation was successfully performed. Following the surgery (2 h), trachea was extubated. Post-operative recovery was uneventful.In cervical spine abnormality, even though awake fibre-optic intubation is the safest gold standard, there are several other options as well.[345] In our patient, we decided to secure the airway under general anaesthesia with step-wise decisions. When intubation with Airtraq failed, direct laryngoscopy with MILS was tried, and the patient could be successfully intubated using stylet and OELM. In this situation, Plan A for airway management was intubation with Airtraq which failed, whereas Plan B was intubation with direct laryngoscopy (with OELM, stylet) which succeeded.During the second surgery, we chose direct laryngoscopy (with OELM, stylet) as Plan A because this had been successful previously. Unfortunately, this failed. This could be due to the airway mucosal oedema of the intraoral approach of the first surgical procedure and the translaminar screw fixation which could have further restricted the neck movements. Although bougie insertion may not be useful in Grade 4 laryngoscopic view, it was tried as a part of blind intubation. Second attempt with Airtraq (Plan B) succeeded. While Airtraq had failed as Plan A during the first surgery, it was successful as Plan B during the second surgery. Exact cause of failure of videolaryngoscope in the first instance is not known. It was the same experienced anaesthesiologist who managed during both the times. This illustrates the dynamic nature of the airway in the same patient during two different surgical contexts.
Figure 1