Anaesthesia and Larygomalacia

Dear Sir,

I read with interest the manuscript Anaesthetic Management of a Child with Congenital Laryngomalacia for Cleft Lip Surgery in April 2010 issue by Kumar et al and appreciate the successful management.¹ Here I would like to share our experience of anaesthetizing two infants with larnygomalacia-one for umblicial hernia repair and other for diagnostic bronchoscopy.

Both infants parents gave history of voice on respiration since 1month of age , frequent episodes of cough and history suggestive of Gastrooesophageal reflux .

The patient posted for umblicial hernia repair was 4mth old, 4kg and malnourished and diagnosed case of laryngomalacia on previous bronchosopy. As surgery was lower abdominal and of short duration we preferred proseal LMA with caudal approach. Standby ventilator was kept ready in PICU along with ENT surgeon, for emergency tracheostomy . Patient was induced and maintained with ketamine, propofol, fentanyl, o₂, N₂o, and sevoflurane. Ketamine was used as it will not only decrease the dose of propofol but also help in maintaining the airway. Paracetamol suppository was used for postoperative analgesia. Surgery went smoothly for half an hour and all vitals were within normal limit including oxygen saturation (spo₂). LMA was removed in deeper planes avoiding coughing episodes, shifted in postoperative ward in left lateral position with oxygen through ventimask at flow rate of 10 lit/minute. In postoperative ward, for intial half an hour patient showed intercoastal retraction and inspiratory stridor but after nebulisation and left lateral position, patient's condition improved. Patient's saturation never fell down below 90%.

The second 3 mths old, 4kg, infant came with suddent onset of respiratory distress in PICU and collapse of upper lobe of lung on X ray. Patient was taken in the Operation theatre for diagnostic bronchoscopy, suspecting foreign body as the cause of symptoms. With all due precautions and high risk consent, we nebulised the patient with 1ml, 2%lignocaine in preoperative ward. Patient was sedated with midazolam ,fentanyl and ketamine. Patients oral cavity was sprayed with 10% lignocaine and brochoscopy done. On bronchoscopy no foreign body was found but tracheomalacia was diagnosed-probably which was the cause of aspiration induced pneumonia followed by respiratory distress. Patient improved after 15 days of intensive treatment in paediatric intensive care unit.

Larnygo -tracheomalacia is a rare yet serious condition associated with high mortality and often requires prolonged intubation and mechanical ventilation. It is the most common congential abnormality of larynx and most common cause of noninfective stridor in children appearing few weeks to months after birth, more in inspiration, crying and supine position. Preoperative assessment of these patients should include a careful history targeted to identify situation and positions that worsen or improve obstructive symptoms. Airway manage-ment of these patients is challenging with risk of total airway obstruction. Possible anaesthetic options have been described as-sedation with topical anaesthesia ,general anesthesia with inhalational or intravenous methods.² LMA is a better option than endotracheal tube as it decreases postoperative coughing episodes upon emergence from anaesthesia. Deep extubation allows a smoother recovery.

We totally agree with the authors that this condition should be known to all paediatric anesthesiologists as these patients require careful preoperative assessment, thoughtout plan for airway management, backup options and a surgeon on standby.