RETROGRADE FIBEROPTIC INTUBATION IN A CHILD WITH NAGERS SYNDROME

Purpose: The authors describe a retrograde fibreoptic technique for tr acheal intubation in a micrognathic child with a tracheo-cutaneous fis tula. Clinical features: A four-year-old child with Nager's syn drome presented for surgical closure of a tracheocutaneous fistula. A trache ostomy tube had been placed in the neonatal period for management of u pper airway obstruction due to severe micrognathia. At 2 1/2 yr of age , after a successful mandibular advancement procedure, the tracheostom y was removed and the child allowed to breathe through the natural air way. Preoperative physical examination revealed an uncooperative child , unable to open her mouth due to limited temporo-mandibular motion. T he child was first anaesthetized with ketamine, 70 mg im, then halotha ne by mask. The authors were unable to open the child's month sufficie ntly to allow rigid laryngoscopy. Attempts at oral and nasal fibreopti c intubation were unsuccessful. Ultimately, the authors were able to i ntubate nasally by passing an ultrathin Olympus LF-P laryngoscope unde r direct vision through the tracheocutaneous fistula in a cephalad dir ection, through the larynx and nasopharynx, then out the nares. An end otracheal tube was then advanced over the fibreoptic scope and positio ned distal to the tracheocutaneous fistula. The surgical procedure was successfully accomplished and the trachea was extubated postoperative ly without difficulty. Conclusion: Retrograde fibreoptic intubation ma y be an option for airway management of a select group of children who cannot be intubated by traditional techniques.