DIFFICULT INTUBATION DUE TO FACIAL MALFOR MATIONS IN CHILDREN - USE OF THE LARYNGEAL MASK AIRWAY

Variations in anatomy of the bony and soft-tissue structures of the ne ck and facial cranium due to trauma, disease, or dysmorphic syndromes may lead to severe intubation problems. These patients are admitted fo r mandibulofacial and otolaryngologic surgery. It is important to insp ect the patient's outer and inner pharyngeal structures carefully duri ng preoperative assessment, as suggested by Mallampati [5]. The observ er estimates the facility of intubation by inspection of the faucial p illars, soft palate, and uvula. Unfortunately, even careful examinatio n does not predict every case of difficult intubation, so that unexpec ted problems may occur. There may also be difficulties in ventilating these patients with a face mask. Safe intubation is possible in these cases using the laryngeal mask airway (LMA) [1, 6, 7], laryngoscopy wi th a rigid optical aid [2], and the fibreoptic bronchoscope. Case repo rt. We report a 14-month-old girl with Goldenhar's syndrome (oculo-aur icular dysplasia) [3] who presented for soft-palate surgery. This synd rome belongs to the group of cranio-mandibular-facial malformations; t he main symptoms are congenital unilateral malformations in the area o f the 1st and 2nd branchial arches. The patient's jaw was hypoplastic with aplasia of the temporo-mandibular joint, which led to asymmetry o f the lower face and an extremely short mandible. Additionally, we obs erved a large tongue in relation to the small jaw. Macrostomia is part of the syndrome, and may lead to underestimation of intubation proble ms. As the faucial pillars were visible but the uvula was masked by th e base of the tongue, we assigned our patient to Mallampati class 2 [5 ]. Other findings in the syndrome can be malformations of the eyes, ea rs, heart, and spinal column. Our patient had complete atresia of the right outer ear and a subconjunctival lipoma. Due to these conditions, we expected a difficult intubation. Anaesthesia was induced with 250 mg methohexitone rectally and continued with halothane via a Rendell-B aker mask. After relaxation with vercuronium, laryngoscopy was perform ed. Due to the extremely short chin and relatively large tongue, it wa s impossible to visualise the vocal cords or epiglottis. Safe face-mas k ventilation was also difficult. Therefore, we decided to introduce a LMA, which was easily done. Since reconstruction of the soft palate w as not possible with a LMA, we used a fibreoptic bronchoscope to intub ate the patient with a Vygon tube via the lumen of the LMA. Fixing the endotracheal tube with a long forceps, the LMA was easily removed. Th e LMA was successfully applied at a second procedure for a change of d ressing. Discussion. In cases of difficult mask ventilation and intuba tion problems, the LMA improves the safety of both patient and the ana esthetist. Airway management with the LMA is easy and safe and without the risk of trauma caused by violent attempts to position an endotrac heal tube by normal laryngoscopy when abnormal anatomy is present or u nexpected problems occur. When a difficult intubation can be expected (e.g., in facial dysmorphic syndromes such as Goldenhar's syndrome, Pi erre-Robin syndrome, or Franceschetti's syndrome) we recommend conside ring the LMA as a safe additional tool for airway management.