Sir,A review of the pediatric closed claim cases reveals inadequate ventilation or failed intubation among common causes of anesthesia-related deaths. Unlike adults, no validated classification exists for difficult airway assessment in pediatric population.[1] Anticipated difficult airway includes congenital syndromes or anatomy such as temporomandibular joint dysfunction or neck contracture. A common feature of many of these syndromes is micrognathia, ankyloglossia, or both leading to difficult glottic visualization.[2] Mallampati classification does not accurately predict a poor glottis visualization in the pediatric population.[1] We discuss difficult airway management of a 3-year-old male child with micrognathia and ankyloglossia, diagnosed with Grade V left vesicoureteric reflux and listed for laparoscopic transperitoneal left ureteric reimplantation [Figure 1].
Figure 1
Child with micrognathia
Child with micrognathiaAfter adequate nil per oral status, the child was brought to operating room without any premedication. Routine anaesthesia monitors was placed and age appropriate difficult airway trolley was kept on standby. Anesthesia was induced with inhaled sevoflurane 6–8%, intravenous access secured; midazolam 0.3 mg, fentanyl 30 μg, and propofol 10 mg were administered. Under spontaneous ventilation, conventional direct laryngoscopy (DL) with straight blade was attempted. A Cormack and Lehane (CL) Grade IV laryngoscopic view was encountered owing to the tongue falling on either side of the blade. A repeat attempt was done with curved blade, but the tongue could not be deviated to the left side because of ankyloglossia. Two failed attempts at DL prompted us to use GlideScope® video laryngoscope (GVL) which enabled a CL Grade III glottic visualization, and we were able to intubate the trachea with 4.5 sized uncuffed endotracheal tube. Subsequently, the child was paralyzed with 2 mg of vecuronium and maintained with oxygen, air, and sevoflurane mixture. During the entire episode till successful intubation, we were able to maintain oxygenation.After completion of surgery and return of spontaneous ventilation, muscle relaxation was reversed and child extubated.Keeping in mind the nature, duration, and positioning during surgery, we ruled out the use of laryngeal mask airway (LMA) as our first tool to secure the airway.Kuzma et al. used LMA assisted fiberoptic-guided intubation for a child with Escobar syndrome.[3] Airtraq optical laryngoscope and GVL have been used successfully in pediatric patients with the craniofacial anomalies.[4] We are of the opinion that ankyloglossia, by preventing tongue fall, allowed us to ventilate the patient and gave us precious time to exercise other options of securing the airway.While ankyloglossia made bag-mask ventilation easy, it along with micrognathia resulted in limited space for blade maneuverability during DL and GVL, thereby hampering glottic visualization. Although we used GVL to secure the airway, we wish to suggest that rather than taking multiple attempts at DL or GVL, fiberoptic-guided intubation should be the first choice for endotracheal intubation. Further, a child with micrognathia should always be evaluated for ankyloglossia during preanesthetic evaluation. However, a larger study in children with ankyloglossia and micrognathia is required to further cement our suggestion.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Figure 1