Paediatric King Vision® videolaryngoscope in a case of infantile oral mass: A useful alternative to fiberoptic bronchoscope as a first choice in paediatric difficult airway.

Sir,

Paediatric airway management poses unique challenges to anaesthesiologist. It is always a nightmare for all anaesthesiologist when a child comes with a huge oral mass.[1] Paediatric fiberoptic intubation is usually the first choice in most of the cases presenting with such clinical history. Can Paediatric King Vision® videolaryngoscope (with size 1 blade) be a useful first choice alternative to fiberoptic bronchoscope in such a case especially when fiberoptic bronchoscopy may be difficult?

A 4-month-old male infant presented with history of mass arising from oral cavity which was rapidly increasing in size for the past 2 months. The child had history of difficulty in feeding for the past 1 month. There was no history of difficulty in breathing or noisy breathing when the child slept or cried. Oral examination revealed a 6 × 4 cm mass arising from the oral cavity [Figure 1a], the inner extent and origin could not be traced as the child was not cooperative. There was a small opening of approximately 1 × 1 cm present below the mass at the right corner of the mouth (through which the child was feeding). There was no sign of respiratory distress in both supine and erect posture. Noncontrast computed tomography of head and neck [Figure 1b and c] revealed a mass arising from left maxilla extending into the oral cavity with left nasal cavity being obliterated. The soft palate, nasopharynx, oropharynx, and larynx appeared normal and free from the mass. The child was posted for excision of the mass under anaesthesia. A 24 G intravenous line was secured preoperatively. On the day of surgery, a larger sized face mask was carefully selected to include the entire oral mass which was protruding out so that there should not be a leak when mask ventilation were to be attempted. The mass was covered by a wet gauze piece before applying face mask. Seal of the face mask was confirmed by regular end-tidal CO2(EtCO2) tracing. Anaesthesia was induced using sevoflurane and neuromuscular blockade was achieved with intravenous (iv) injection succinylcholine 2 mg/kg after reassessing the mouth opening and for possibility of positive pressure ventilation. Mouth opening was considerably better from the initial 1 × 1 cm at the right corner of the mouth.

Figure 1

A case of Infantile oral mass intubated using paediatric King Vision videolaryngoscope. (a) Huge oral mass with reduced mouth opening. (b and c) Computed tomography image of the oral mass arising from the hard palate. (d) Infant intubated through a small opening at the right corner of the mouth using paediatric King Vision Videolaryngoscope

As per preoperative plan, laryngoscopy was attempted using King Vision® with size 1 blade. The size 1 blade could just be accommodated into the oral cavity in our case. With Cormack–Lehane grade 2 view of the glottis, the trachea was intubated using a 3 size uncuffed tube with stylet in situ with preformed curvature resembling the curvature of the size 1 King Vision® blade [Figure 1d]. The surgery took around 90 minutes. The oral mass was excised from the hard palate. The trachea was extubated on table once the child became fully awake and gained neuromuscular recovery.

Oral fiberoptic-guided intubation would be relatively difficult in a paediatric population with a huge mass which was almost covering the entire oral cavity. Paediatric videolaryngoscope such as King Vision® with appropriate blade would be an ideal first choice (provided the mouth opening was adequate to accommodate that particular size of the blade) when compared to oral fiberoptic-guided intubation, in case of large oral mass with high chances of bleeding. Fiberoptic bronchoscope-guided intubation becomes practically impossible in the event of accidental bleeding from the oral mass. Direct laryngoscopy with size 1 miller blade would also be difficult as there is a huge mass arising from maxilla which would come into the path of line of sight.

On table airway reassessment (e.g. mouth opening in this case), once the child becomes sedated under sevoflurane induction, will help anaesthesiologists in choosing appropriate airway management plan. This case management has also shown that paediatric King Vision® videolaryngoscope can be considered safely in scenarios where mouth opening is greatly reduced.[2] Paediatric King Vision® videolaryngoscope with size 1 blade can therefore be used as a useful alternative to fiberoptic-guided intubation in infants presenting with large oral mass and reduced mouth opening.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.