Dear Editor,
A 12-year-old boy, diagnosed case of Crouzon syndrome with midface hypoplasia and reduced posterior airway space had undergone fronto-orbital advancement and infra-orbital rim augmentation for recurrent globe subluxation earlier. Lefort III osteotomy and rigid external distractor placement was done 2 weeks back. This time, the patient presented with pus discharge from left lateral brow region for evaluation.
On examination, it was found that the rigid external distractor was in situ anteriorly with asymmetric midface. Airway examination showed mouth opening to be adequate with normal tongue protrusion. We planned performing the surgery under general anesthesia (GA) with intravenous induction (IV) and quickly securing airway with proseal laryngeal mask airway. Patient was pre-oxygenated for 3 min with facemask placed across mouth and induced with fentanyl 2mcg/kg, glycopyrrolate 0.1mg and propofol 2mg/kg.
Size 2.5 proseal was kept preloaded with pediatric bougie through gastric port with the distal tip of bougie protruding 15cm beyond proseal [Figure 1a]. Following induction when jaw was relaxed, bougie preloaded proseal was inserted blindly [Figure 1b]. Correct placement was confirmed with regular endtidal carbon dioxide waveforms, and auscultation. There was no desaturation during proseal insertion, which was correctly placed in the first attempt and took less than a minute to secure the airway. Anesthesia was maintained with sevoflurane in oxygen air mixture and intraoperative period was uneventful. Surgery lasted for 30 min and proseal was removed when patient was fully awake.
Figure 1.
Bougie preloaded proseal (a) and proseal in place after insertion (b)
Patients with rigid external distractor in place pose unique challenges to the anesthetist in securing the airway. As the distractor was placed anteriorly it would obstruct glottic view during direct laryngoscopy, if attempted. As metal wires from distractor were attached to the maxilla there was no space to hold the face mask and hence mask ventilation was not possible. Awake fibreoptic intubation (FOI) was also not feasible as patient was uncooperative. Use of pediatric videolaryngoscope could have been a safe option. However, it was not available at that time. Oral FOI following IV induction was not considered as it would be technically more difficult than nasal FOI and delay in securing airway was riskier. Total intravenous anesthesia is dangerous in such patients in view of atrophic upper airway, preponderance for airway obstruction, and inability to mask ventilate in case of an emergency.
Traditional insertion of proseal could be difficult sometimes and may require repeated attempts.[1,2] Bougie preloaded technique is considered as a quick and easy method with good success rate,[3,4] as on insertion the bougie mostly will enter the esophagus leading to proper placement. We did not consider use of introducer tool for proseal[5] or I gel as appropriate sizes were unavailable. Blind passage of preloaded bougie should be done with caution because of potential damage to soft tissues of upper airway and esophagus where it is intended to be placed. Appropriate postoperative follow-up for such soft tissue injuries is important.
It is concluded that airway can be quickly secured in the first attempt with bougie preloaded proseal in patients with difficult airway having adequate mouth opening when FOI under GA is considered riskier and time consuming.
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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.
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Conflicts of interest
There are no conflicts of interest.
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