ISSN:
1432-055X
Keywords:
Schlüsselwörter: Fehlbildungen, angeborene: kranmandibulo-faziale Dysmorphien – Dysplasia oculo-auricularis: Goldenharsyndrom – Intubation, erschwerte: Kehlkopfmaske, fiberoptisches Endoskop
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Key words: Malformations, congenital: craniomandibulo-facial dysmorphia – Dysplasia oculo-auricularis: Goldenhar's syndrome – Intubation, difficult: laryngeal mask airway, fiberoptic bronchoscope
Source:
Springer Online Journal Archives 1860-2000
Topics:
Medicine
Description / Table of Contents:
Abstract. Variations in anatomy of the bony and soft-tissue structures of the neck and facial cranium due to trauma, disease, or dysmorphic syndromes may lead to severe intubation problems. These patients are admitted for mandibulofacial and otolaryngologic surgery. It is important to inspect the patient's outer and inner pharyngeal structures carefully during preoperative assessment, as suggested by Mallampati [5]. The observer estimates the facility of intubation by inspection of the faucial pillars, soft palate, and uvula. Unfortunately, even careful examination does not predict every case of difficult intubation, so that unexpected 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 with a rigid optical aid [2], and the fibreoptic bronchoscope. Case report. We report a 14-month-old girl with Goldenhar's syndrome (oculo-auricular dysplasia) [3] who presented for soft-palate surgery. This syndrome belongs to the group of cranio-mandibular-facial malformations; the main symptoms are congenital unilateral malformations in the area of the 1st and 2nd branchial arches. The patient's jaw was hypoplastic with aplasia of the temporo-mandibular joint, which led to asymmetry of the lower face and an extremely short mandible. Additionally, we observed a large tongue in relation to the small jaw. Macrostomia is part of the syndrome, and may lead to underestimation of intubation problems. As the faucial pillars were visible but the uvula was masked by the base of the tongue, we assigned our patient to Mallampati class 2 [5]. Other findings in the syndrome can be malformations of the eyes, ears, 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-Baker mask. After relaxation with vercuronium, laryngoscopy was performed. Due to the extremely short chin and relatively large tongue, it was impossible to visualise the vocal cords or epiglottis. Safe face-mask ventilation was also difficult. Therefore, we decided to introduce a LMA, which was easily done. Since reconstruction of the soft palate was not possible with a LMA, we used a fibreoptic bronchoscope to intubate 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. The LMA was successfully applied at a second procedure for a change of dressing. Discussion. In cases of difficult mask ventilation and intubation problems, the LMA improves the safety of both patient and the anaesthetist. Airway management with the LMA is easy and safe and without the risk of trauma caused by violent attempts to position an endotracheal tube by normal laryngoscopy when abnormal anatomy is present or unexpected problems occur. When a difficult intubation can be expected (e.g., in facial dysmorphic syndromes such as Goldenhar's syndrome, Pierre-Robin syndrome, or Franceschetti's syndrome) we recommend considering the LMA as a safe additional tool for airway management.
Notes:
Zusammenfassung. Anatomische Veränderungen, Verletzungen und Fehlbildungen im Hals- und Kopfbereich sind Gründe erschwerter bis unmöglicher konventioneller Intubation. Auch eine präoperative Einschätzung anhand der Einsehbarkeit von Tonsillen, Uvula und weichem Gaumensegel korreliert nicht immer mit dem späteren Intubationssitus. Wir berichten im folgenden über eine 14 Monate alte Patientin mit Goldenharsyndrom (Dysplasia oculo-auricularis), bei der ein Weichgaumenverschluß durchgeführt werden sollte. Das Syndrom gehört zum Formenkreis der kranio-mandibulo-fazialen Dysmorphien. Typisch sind Entwicklungsstörungen im Bereich des 1. und 2. Kiemenbogens mit Fehlbildung von Augen-, Ohren- und Kieferanlage. Die resultierende Hypoplasie des aufsteigenden Unterkieferastes mit Mikro-, Retrogenie kann zu erheblichen Intubationsproblemen führen. Nach Narkoseeinleitung mit Brevimethal rektal, Halothan und Vecuronium wurde eine Einstellung mit dem Laryngoskop vorgenommen. Im relativ zu kleinen Hypopharynx ließ sich die Glottis nicht einsehen. Wir entschieden uns eine Kehlkopfmaske einzulegen, was problemlos gelang. Da diese für die geplante Operation nicht belassen werden konnte, plazierten wir mit Hilfe einer Fiberoptik einen Vygon-Tubus durch den Ansatzschlauch der Kehlkopfmaske. Durch die Kombination von Kehlkopfmaske und fiberoptischem Endoskop als Intubationshilfsmittel waren die Atemwege der kleinen Patientin zu jeder Zeit gesichert. Wir empfehlen daher, bei zu erwartender schwieriger Intubation auch die Kehlkopfmaske grundsätzlich mit in Betracht zu ziehen.
Type of Medium:
Electronic Resource
URL:
http://dx.doi.org/10.1007/s001010050119
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