Easy airway management using the i-gel™ supraglottic airway in a patient with Treacher Collins syndrome

provided the original work is properly cited. CC Treacher Collins syndrome (Mandibulofacial Dysostosis, TCS) is characterized by antimongoloid slanting of the palpebral fissures, coloboma of the lower lid, micrognathia and hypoplasia of the zygomatic arches, and microtia. TCS appears to be inherited in an autosomal dominant fashion or occurs sporadically, and is a congenital malformation of the 1st and 2nd branchial arches [1]. It is common for TCS to lead to difficulties in intubation [2], and many techniques for airway management have been reported, such as intubation under fiberoptic bronchoscopy, the use of a laryngeal mask airway (LMA), fiberoptic intubation through LMA, and even tracheostomy [2]. We report a case of successful airway management with the i-gel (Intersurgical Ltd., Wokingham, UK) after failed attempts with fiberoptic intubation and videolaryngoscope in a patient with TCS who had undergone emergency abdominal surgery. A 25-year-old man with TCS who was 170.0 cm in height and 68.7 kg in weight was scheduled to undergo an emergency small bowel resection. His symptoms included hematochezia for 2 days and a bleeding Meckel’s diverticulum diagnosed by an enterography CT scan. He was diagnosed with TCS in early childhood, and there was no family history. He also suffered from malocclusion and chronic otitis media without mental retardation or hearing impairment. He had a history of mandibular augmentation with intubation difficulty at a different hospital at age 18, and cerebral thalamic infarct without neurologic sequelae at age 22. Physical examination showed the characteristic findings of TCS. Preoperative laboratory tests were all within normal limits and no abnormal findings were shown on chest radiograph or electrocardiograph. Upon arrival in the operating room, an electrocardiogram, and automated blood pressure cuff, pulse oximetry (SpO2), end-tidal CO2 and Bispectral index (BIS) monitors were applied. The patient’s preinduction vital sign was stable. The evaluation of his airway revealed mandibular hypoplasia, a narrow mouth opening (1.5 finger breadths), a short thyromental distance (1.5 finger breadths), and Mallampati classification grade 4. Because we anticipated difficulty intubating the patient, we planned a videolayrngoscopic approach (McGrath MAC, Covidien, USA) and fiberoptic intubation (MAF-GM airway mobilescope, Tokyo, Olympus, Japan) under sedation with dexmedetomidine infusion. With O2 6 L/min via a nasal prong, a loading dose of dexmedetomidine 1 μg/kg was infused over 10 min with a maintenance infusion rate of 0.5 μg/ kg/hr. Prepared propofol 1–2 μg/kg/min and remifentanil 3–10 ng/kg/min were administered via target-controlled infusion (Orchestra Base Prima, Fresenius Vial, Brezins, France). After the BIS fell below 60 while self-respiration was still maintained, we attempted videolaryngoscopy twice, but a difficult videolaryngoscope insertion due to the narrow mouth opening resulted in a failure to visualize the vocal cord. We then tried trans-nasal fiberoptic intubation with a wire endotracheal tube #6.0 twice, but failed to visualize the vocal cords due to the patient’s gag reflex and small supraglottic space. Vitals were maintained in the following ranges: SpO2 85–100%, BP 100–150/50–95 mmHg, HR 50–100 beats/min, and BIS under 60. We suspected the major barriers to successful intubation were the narrow opening of mouth and the small supraglottic area. For these reasons, we decided to use the i-gel #3 insertion rather than LMA for airway maintenance, and it was inserted within 30 seconds of the