Successful tracheal intubation using fiberoptic bronchoscope via an I-gel™ supraglottic airway in a pediatric patient with Goldenhar syndrome -A case report-
A 4-year-old boy (55 months, 16.3 kg, 102 cm) was diagnosed with chronic hypertrophic tonsillitis and adenoid vegetation due to severe stertorous breathing and sleep apnea, and he was hospitalized in the otorhinolaryngology department for tonsillectomy and adenoidectomy. Preoperative laboratory tests, electrocardiogram, and chest radiology were unremarkable. However, the patient had severe stertorous breathing and recently developed mild dry coughing two days prior to surgery. According to the preoperative interview with the guardian one day before the surgery, the patient was born via cesarean section due to breech presentation weighing at 3.5 kg and had no specific medical history. An intramuscular injection of 0.25 mg atropine was given as premedication 30 minutes prior to entering the operating room. The patient's guardian was in attendance in the waiting room for psychological stabilization.\nWhen we approached the patient for induction of anesthesia, malformation was found on the right side of the patient's face. When asked once again about the patient's medical history, it was found that the patient was diagnosed with congenital auricular atresia after birth, and hearing test conducted 3 months after birth confirmed hearing loss of the right ear. Later, the patient was diagnosed with Goldenhar syndrome accomopanying partial loss of the right auricle, conjunctival dermoid, and oral atresia. The right side of the patient's face was less developed compared with the left, thus making his face asymmetric. The auricle was undeveloped, with only a partial earlobe remaining in his right ear (). The Mallampati oral opening view was unavailable due to agitation of the patient, and the patient presented irregular dentition. The patient was sitting on the bed due to dyspnea that occurs in a lying position. While the guardian remained to help stabilize the patient, ketamine (2 mg/kg) was administered to induce anesthesia. With spontaneous breathing intact, the patient was taken to the operating room.\nIn the waiting room, pulse oxygen saturation was measured at 98% in a sitting position. However, after ketamine was given for induction of anesthesia, pulse oxygen saturation fell to 94% in the operating room with the spontaneous breathing intact. Other vital signs showed blood pressure of 125/85 mmHg and heart rate of 170 beats/min. Preoxygenation was performed, and 0.6 mg/kg of rocuronium and 1 µg/kg of fentanyl were administered intravenously. Manual ventilation was attempted using a mask, but the mask did not fit due to facial deformity. For effective manual ventilation, gauze was filled in the buccal area to achieve the best possible fit for the mask. Oral airway was inserted and an open airway was maintained using both hands, and then manual ventilation was attempted with the help of an assistant.\nA skilled anesthesiologist used a #2 Macintosh curved laryngoscope blade to lift the epiglottis with an assistant manipulating the larynx, but failed to check the glottic opening. With a 4.5 mm cuffed tube (Mallinckrodt, Covidien, Ireland) and a stylet, the authors used blind technique for intubation, but it was unsuccessful. A video laryngoscope (GlideScope & GVL 4, Verathon Medical, Canada) was used in the following attempt, but even entering the glottis was difficult due to the narrow oral cavity. Thus, a supraglottic airway device (I-gel™ size 2, Intersurgical, Lithuania) was inserted for proper ventilation. Then a bronchoscope (LF-DP, Olympus, Tokyo, Japan) was inserted through I-gel™ for visualization of the glottic opening, a part of which was shown on the upper side of a the bronchoscopic view. By lifting the mandible and applying pressure on the cricoid cartilage, the authors moved the glottic opening to the center of the the bronchoscopic view. After deciding to attempt fiberoptic bronchoscopic intubation, adequate ventilation was performed. A cuffed 4.5 mm tube was covered with lubricant, and fiberoptic bronchoscopic intubation was performed through a laryngeal mask airway. The tube was placed in a proper depth by checking the carina (). In order to remove the I-gel™ while maintaining the tube, first, the connecting part at the proximal end of the tube was removed. Then, a tube exchanger (Airway exchanger catheter, Cook, Canada), which was thicker than the tube, was used to secure the tube in place. Finally, the I-gel™ was removed (). After cuff ballooning, the tube's connecting part and the respiratory circuit were connected. The authors checked the depth of the tube through a stethoscope and conducted mechanical ventilation.\nDuring the surgery, 1.5 and 2.5 L/min of O2 and air were administered, respectively. Anesthesia was maintained with sevoflurane 2.0-2.5 vol%. Vital signs were maintained, as follows: blood pressure 115-130/70-85 mmHg, heart rate 140-170/min, pulse oxygen saturation 98-100%, and capnogram 32-41 mmHg. The operation was finished after 75 minutes. After the spontaneous breathing of the patient was recovered, 0.004 mg/kg glycopyrrolate and 0.2 mg/kg pyridostigmine was injected intravenously. Then, the patient was extubated and moved to the recovery room. Severe stridor and even transient apnea occurred while the patient was lying in the recovery room. When 5 L/min of oxygen was supplied by a mask, pulse oxygen saturation was up to 98%, but it fell to 84-88% during room air respiration. The patient did not feel much discomfort because he had long been adapted to low oxygen saturation. After being stabilized for 2 hours in the recovery room, the patient was supplied with 2 L/min of oxygen through a nasal cannula and transferred back to the patient's room. Total operative time and anesthesia time were 75 minutes and 105 minutes, respectively, and 80 ml of Hartman solution was administered. On the fourth day following the surgery, the patient was discharged without any further problems.