Horseshoe head holder for optimal airway access in infants with macrocephaly.

Sir,

Hydrocephalus in children before the closure of anterior/posterior fontanellae can result in macrocephaly. Ventriculo-peritoneal (VP) shunt surgery under general anaesthesia is frequently indicated in paediatric hydrocephalus.[1] Hydrocephalus with macrocephaly causes undue neck flexion in a supine child, compromising the access to airway and ease of endotracheal intubation.[2] Undue neck flexion compounds the airway access difficulty in the already anatomically different paediatric airway with large tongue, omega-shaped epiglottis, cephalic-located larynx, angled vocal cords and a narrow sub-glottis.[34] We describe here the approach we follow for optimal positioning for ease of airway access in paediatric macrocephaly.

Achieving the classic sniffing position is a standard of practice in anaesthesia, for endotracheal intubation. This position aims at obtaining a near horizontal glabella-chin (GC) plane, external auditory meatus-suprasternal notch (EO-SN) plane and an open anterior neck space.[56] This manoeuvre aligns the laryngeal, pharyngeal and tracheal axis in-line and improves the intubating condition. In children with macrocephaly, the GC plane and EO-SN plane are grossly misaligned with limited anterior neck space. Placing shoulder rolls and/or elevating the infant with trunk rolls or a ramp of sheets are the commonly practised techniques in infants with macrocephaly to circumvent the collapse of airway in neutral position.[2] However this technique is not without limitations such that this entails the infant's head unstable unless a tailored head-ring support is also used. Placement of such head-ring supports can further increase neck flexion which may require further manipulations of the truncal support rolls to compensate this.

We use the adult size Mayfield® cranial stabilisation horse- shoe head holder[7](Integra Neurosciences, New Jersey-08540) at our institution for optimal airway positioning in macrocephalic infants undergoing VP shunt for hydrocephalus [Figure 1a]. A horizontal GC plane, EO-SN plane and open anterior neck space is achieved prior to endotracheal intubation with vertical and lateral adjustments of the horse-shoe head holder [Figure 1b]. The adjustable pad base of the head holder well accommodates the infant's macrocephaic head. After successful endotracheal intubation, VP shunt procedure can be contemplated with the horse-shoe head-holder in-situ, with added axial traction if required. Warm water-baths for truncal surface warming can be easily used with this technique. Our technique does not warrant multiple attempts at infant positioning as required if using the truncal/shoulder rolls or truncal ramp of sheets.

Figure 1

(a) Depicts placement of macrocephalic head of an infant, about to undergo ventriculo-peritoneal shunt for hydrocephalus, on Mayfield® cranial stabilisation horseshoe head holder. (b) Horizontal alignment obtained on glabella-chin plane and external auditory meatus-suprasternal notch plane with an open anterior neck space with the use of Mayfield® cranial stabilisation horseshoe head holder

The Mayfield® horseshoe head holders are commonly available in every neurosurgical theatre. To our knowledge this is the first description of Mayfield® cranial stabilisation horse-shoe head holder as an airway positioning aid in neurosurgery. We present our technique as a simple yet novel method to circumvent difficult airway scenarios in infants with macrocephaly.

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.