Awake videolaryngoscopy in a child with a predicted difficult airway due to a large craniofacial vascular tumour

A 13‐year‐old, 28 kg, short‐statured (127 cm) male presented with a history of headache and progressive facial swelling associated with bilateral proptosis, visual loss, palatal distortion and episodic profuse nasal bleeding (Fig. 1a and b). Magnetic resonance imaging (MRI) revealed a large irregular lesion (7.5 cm × 9.5 cm × 11 cm) in the frontal lobes, extending into the ethmoid and sphenoid sinuses, nasopharynx, left orbit and optic chiasma (Fig. 1e). An endoscopic biopsy of the mass was planned. Given the anticipated difficulty with bag‐mask ventilation and nasopharyngeal patency, awake videolaryngoscopy with orotracheal intubation was planned.

Figure 1.

Front (a) and side (b) profile of the patient; glottic view on C‐MAC^® (c) and (d); and a representative magnetic resonance imaging slice demonstrating the mass (e).

Topical anaesthesia of the patient's airway was achieved with 4 ml of lidocaine 4% gargle and 3 puffs of lidocaine 10% spray, supplemented with a bilateral superior laryngeal nerve block with 2 ml of lidocaine 2%. A dexmedetomidine infusion (0.5 μg.kg⁻¹) was given over 10 min for anxiolysis. Laryngoscopy was performed using a C‐MAC^® videolaryngoscope (Karl Storz GmbH & Co. KG, Tuttlingen, Germany) with a size 3 blade, with lidocaine 2% jelly applied to the dorsal aspect. A percentage of glottic opening (POGO) score of 0 was obtained (only the epiglottis could be seen) and tracheal intubation was unsuccessful (Fig. 1c). Because the child had moved and coughed during the first attempt, fentanyl 30 μg i.v. was given prior to a second attempt at laryngoscopy. The patient remained responsive to verbal prompts throughout and the second attempt at laryngoscopy was well tolerated and with a POGO score of 100. The child's trachea was then intubated by a senior anaesthetist using a 6 mm internal diameter cuffed tracheal tube loaded onto a stylet (Fig. 1d). General anaesthesia was then induced with propofol 50 mg i.v., and maintained with sevoflurane 2% in 50% oxygen/air mixture with intermittent boluses of atracurium. The surgery was uneventful.

Videolaryngoscopy is a time‐efficient tool which is emerging as an alternative technique for awake tracheal intubation [1, 2]. This report demonstrates the feasibility of this approach in children, but as with many aspects of paediatric anaesthesia, a flexible and patient‐centred approach may be needed to facilitate procedural success.