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  • 1. burns 36 (2010) e78–e81 available at www.sciencedirect.com journal homepage: www.elsevier.com/locate/burnsCase reportSecuring the airway in a child with extensive post-burncontracture of the neck: A novel strategyThai Er Wong a,*, Lay-Hooi Lim a, Wee Jin Tan b, Teik Hooi Khoo ca Department of Plastic and Reconstructive Surgery, Penang Hospital, Residency Road, 10990 Penang, Malaysiab Department of General Surgery, Penang Hospital, Residency Road, 10990 Penang, Malaysiac Department of Anaesthesiology and Intensive Care, Penang Hospital, Residency Road, 10990 Penang, Malaysiaarticle info 2. Case reportArticle history:Accepted 14 October 2009 An eleven-year-old girl presented with severe scar contrac- tures involving the neck, face, anterior chest, anterior abdomen, and upper extremities leading to a deformity whereby the chin, chest and both the upper arms were fused together by thick hard scars (Fig. 1). She had sustained 50%1. Introduction burns in a longhouse fire in a remote area of Borneo at six years of age.Burn contractures of the neck cause disfigurement and The contractures caused her to adopt a stooped posturefunctional limitation, and optimal primary management can from increased thoracic kyphosis and airway examinationreduce the frequency and degree of deformity. Hence in the revealed a Mallampati Grade IV airway [7,8] with no clinicallydeveloped world, severe contractures are uncommon but to discernible thyromental distance or neck extension. Thesurgeons working in the developing world, whether perma- cervico-mental and the mento-sternal angles were completelynently or as part of humanitarian missions, these clinical obliterated by thick stiff scars and the trachea was totallyscenarios continue to present themselves [1–5]. impalpable. Perioperative airway management in these patients may Preoperative X-rays and CT scan to assess her airwaypresent serious challenges and consideration of related passage and related structures revealed a horseshoe-shapedanaesthetic issues is necessary during surgical decision- passage taking an inverse U-turn from the oropharynx to themaking. A collaborative approach between surgeon and trachea (Fig. 2).anaesthetist can provide a range of traditional and modern The first attempt was performed using airway topicalisa-options for the accomplishment of a secure airway in these tion with cocaine paste to the nasal mucosa and lignocainecircumstances and these have been well-documented nebulisation, followed by awake fibreoptic bronchoscopy. This(Table 1) [1,2,5,6]. However, in the paediatric patient, the failed due to extreme difficulty in negotiating the distortednumber of options become much more limited due to the airway and her inability to tolerate the procedure after aninability of the child to tolerate the manoeuvres required in initial phase of cooperation. Subsequently anaesthesia wasthese techniques. We report a case of a child with severe burn induced using oxygen and sevoflurane via a Patil-Syracusecontracture involving the neck, face, chest and shoulders mask (PS mask), an anaesthetic face mask which allows forwhereby, after initial failures, endotracheal intubation was passage of a bronchoscope cum endotracheal tube through afinally achieved by means of a novel combined surgeon– capped port, but attempts at bronchoscopic intubation failedanaesthetist effort. because the ensheathed endotracheal tube could not be * Corresponding author. Tel.: +60 42225319; fax: +60 42225548. E-mail addresses: wongtedr@yahoo.com, wongtedr@gmail.com (T.E. Wong).0305-4179/$36.00 # 2009 Elsevier Ltd and ISBI. All rights reserved.doi:10.1016/j.burns.2009.10.016
  • 2. burns 36 (2010) e78–e81 e79 Table 1 – Options for airway management in scar efforts were ceased before clinical decompensation to avoid contractures of the neck. catastrophe. A second attempt 11 days later also failed. She Conventional immediate intubation recovered readily from both trips to the operating theatre but Awake intubation with flexible fibreoptic bronchoscope remained as an inpatient because home for her was in a Awake intubation with rigid fibreoptic laryngoscope remote longhouse in rural interior Borneo over a thousand Pre-induction scar release under local anaesthesia then tracheal intubation miles away. Face mask ventilation followed by surgical scar release then Following this, the anaesthetic and surgical team jointly tracheal intubation conceived a strategy utilising a paediatric gastroscope Surgical scar release under ketamine and local anaesthesia then followed by a railroading sequence necessitated by the intubation inability to ensheath the gastroscope with a size 6 endo- Laryngeal mask airway anaesthesia and scar release then intuba- tracheal tube (ETT). The gastroscope was chosen for its tip tion if needed which could be manouvered in multiaxial directions and the Intubating laryngeal mask airway Tracheostomy or cricothyroidotomy under local anaesthesia railroading sequence employed a guide wire, a Cook’s airway exchanger and finally the ETT. The airway exchanger was used because the guide wire was not stiff enough to allowadvanced over the flexible bronchoscope making the U-turn railroading by an ETT.without dislodging the positioned bronchoscope despite After anaesthetising the patient with the PS mask, awarming the tube to increase its pliability. Throughout the traction tongue suture was placed, aiding the surgeon–procedure, the deformity prevented an adequate mask seal endoscopist as he guided the paediatric gastroscope throughresulting in episodes of desaturation of the SpO2 levels to the mask, transorally into the hypopharynx. The guide wire<94%. These repeated spells of desaturation were reversed was inserted into the trachea via the gastroscope under directonly by withdrawal of the bronchoscope, closure of the port of vision and in rapid succession, the gastroscope was removedthe PS mask, traction on the tongue with a silk suture, and a Cook’s airway exchanger railroaded over the guide wire.administration of 100% oxygen and cessation of sevoflurane, The patient was ventilated briefly via the airway exchangerthroughout which the mask was held in position with great after removal of the guide wire before a size 6 ETT was inserteddifficulty because of thick rigid distorting scars. These same into the trachea over the Cook’s airway exchanger (Fig. 2).scars not only displaced the midline structures but also made A post-intubation radiograph revealed the ETT taking anthe surface location of the trachea impossible, hence ruling acute turn with a slight kink causing brief spells of increasedout the possibility of the placement of a retrograde wire end-tidal carbon dioxide on capnography intraoperatively,through the cricothyroid membrane. which ceased after surgical release was completed. Otherwise Direct laryngoscopy with a variety of blades aided by a the remaining period of anaesthesia was uneventful.traction tongue suture, use of a laryngeal mask airway and a Surgical release of the contractures was followed bylighted stylet was uniformly unsuccessful. The entire episode Integra1 resurfacing (Fig. 3). Endotracheal intubation forlasted nearly 3 h. With increasing oedema of the oral subsequent surgical procedures was performed transorallystructures and some bleeding due to the manoeuvres, the in the usual manner.Fig. 1 – Severe post-burn scar contracture involving the neck, face, anterior chest, anterior abdomen, and upper extremities.
  • 3. e80 burns 36 (2010) e78–e81Fig. 2 – A sagittal section of CT scan of the head and neck revealing the horseshoe-shaped passage of the upper airway anddiagrammatic representation of successful intubation in this study case utilising a novel railroading technique. Fig. 3 – Integra resurfacing following the contracture release.3. Discussion of the contracture using face mask ventilation or ketamine followed by tracheal intubation, or rarely, a tracheostomy.With the development of supraglottic airway devices and new Where aids are available, the surgeon becomes an integral partequipment aids for tracheal intubation of the difficult airway, of the effort to accomplish a secure airway for surgery, froma variety of options to secure the airway in the patient with providing a traction tongue suture to ensuring optimumburn contracture of the neck now exist [1–6]. A collaborative theatre set-up to facilitate efficient surgical release.surgeon–anaesthetist approach is able to provide a range of The contracture in this child was considered to be of extremetraditional and modern options (Table 1). severity because the scars were thick, rigid, and totally non- In mild to moderate contractures, where part of the soft pliable, pulling together the lower face, neck, chest, shoulderstissues in the region remain supple, straightforward intuba- and upper arms, in both vertical and transverse vectors. Thattion can be achieved in 1–2 attempts in 93% of cases. In severe the primary injury had occurred at the age of six years, with thecontractures (atlanto-occipital extension of <20 degrees, patient presenting to us at age eleven years, was a significantMallampati Grades III or IV) successful intubation can be point in the history, alerting us to the observation that ongoingachieved in 1–2 attempts in 79.5% of cases [5]. Failed unyielding deformational forces had been active for five years inintubation attempts and multiple airway manoeuvres can a growing skeleton now reaching the growth spurt oflead to traumatic airway complications, hypoxaemia and adolescence, and this was evidenced by the elongated mandibleapnoea, arrhythmias and laryngospasm, with possible cata- and the abnormal curvature of the spine. It was judged that withstrophic consequences. the extreme anatomical distortion evident externally, anato- Where modern intubation aids are not available, the mical distortion of the deeper structures, in particular, of thesurgeon may be required to play the primary role in securing neck vasculature, was a possibility which could not be ruled out.the airway, whether it be by means of a speedy surgical release It was anticipated that tissue planes would not be readily
  • 4. burns 36 (2010) e78–e81 e81identifiable, that the scars would require sharp division and because of extensive scarring in the previous skin graft donorwould not ‘peel apart’ with ease and that surgical release to sites [13,14].allow intubation would take much more time than in the In dealing with burn-induced neck–chest contractures, it isconventional case, and this proved to be so in the actual emphasized that surgical decision-making should be accom-instance. It was also observed early during the failed attempts at panied by consideration of related anaesthetic issues, and aintubation that maintaining a mask seal was precarious, as the collaborative approach between surgeon and anaesthetist isscars and deformity prevented the mask from adapting to the recommended for safe and atraumatic airway management,face and neck in an air-tight fashion and the lack of pliable soft particularly in the paediatric patient.tissue prevented the anaesthetist from applying an all-roundstable grip on both mask and face. The repeated spells of oxygendesaturation, together with the knowledge that ketamine has Conflict of interest statementan ability to increase oral secretions which can in turn can leadto laryngospasm, made it evident that if we were to attempt All authors have no conflict of interest in this case study and insurgical release without intubation, surgeon and anaesthetist the preparation and submission of this manuscript. There arewould be competing intensely for the same severely restricted no financial and personal relationships with other people orand distorted anatomical region, each obstructing the other organisations that could inappropriately influence (bias) theirfrom achieving their tasks safely, possibly leading to cata- work.strophic failures for both. Hence the decision was made to aimto achieve endotracheal intubation from the outset. references Due to the age of the patient and the severity of thedeformity, it was not possible to execute any of the otheroptions listed in Table 1. The retrograde-assisted fibreopticintubation technique was judged unsuitable in this patient. [1] Embu HY, Yiltok SJ, Isamade ES. Anaesthetic management of mentosternal contractures where resources are limited.This technique first described the passage of a guide wire Niger J Med 2008;17(April–June (2)):143–5.through a tracheotomy stoma to facilitate intubation in a [2] Kreulen M, Mackie DP, Kreis RW, Groenevelt F. Surgicalretrograde manner, and was later applied in a micrognathic release for intubation purposes in postburn contractures ofchild with a pre-existing tracheo-cutaneous fistula [9,10]. In the neck. Burns 1996;22(June (4)):310–2.the absence of a stoma, the guide wire can be introduced [3] Ifeanyichukwu Igwilo Onah. A classification system forpercutaneously through the cricothyroid membrane and postburn mentosternal contractures. Arch Surg 2005;140:671–5.then retrieved with a fibreoptic bronchoscope followed by [4] Eipe N, Choudhrie A, Choudhrie R. Neck contracture releaseintubation. It has been applied in patients with laryngeal and reinforced tracheal tube obstruction. Anesth Analgcarcinoma and ankylosing spondilitis where the neck soft 2006;102:1911–2.tissue envelope overlying the trachea is normal [11,12]. In [5] Xue F-S, Liao X, Li C-W, Xu Y-C, Yang Q-Y, Liu Y, et al.this patient, the cervico-mental and the mento-sternal Clinical experience of airway management and trachealangles were non-existent, being completely obliterated by intubation under general anaesthesia in patients with scarthick stiff scars. The surface location of the trachea could contracture of the neck. Chin Med J 2008;121(11):989–97. [6] Dimitriou V, Voyagis G, Malefaki A, Tsoutsos D. Use of thenot be palpated or ascertained in any way to safely and LMA for management of difficult airway due to extensiveprecisely introduce the guide wire into the trachea through facial and neck contracture. Anesthesiologythe scars. The distortion of the airway passage was also 1997;86(4):1011–2.found to limit the use of the fibreoptic bronchoscope greatly [7] Mallampati SR, Gatt SP, Gugino LD, Waraksa B, Freiburgerin this case. D, Liu PL. A clinical sign to predict difficult intubation: a After initial failures, our successful manoeuvre consisted of prospective study. Can Anaesth Soc J 1985;32:429–34.a period of assisted mask ventilation over a traction tongue [8] Samsoon GLT, Young JRB. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987;42:487–90.suture, direct passage of a guide wire into the trachea via a [9] Butler FS, Cirillo AA. Retrograde tracheal intubation. Anesthpaediatric gastroscope and a railroading sequence using the Analg 1960;333–8.guide wire, a Cook’s airway exchange catheter and the ETT. [10] Przybylo HJ, Stevenson GW, Vicari FA, Horn B. Hall SCThese manoeuvres accomplished airway control in the child retrograde fibreoptic intubation in a child with Nager’sswiftly, without any trauma to the upper aerodigestive tract syndrome. Can J Anaethesia 1996;43(July (7)):697–9.and without any spells of oxygen desaturation. [11] Bissinger U, Guggenberger H, Lenz G. Retrograde-guided fibreoptic intubation in patients with laryngeal carcinoma. It is important to note that even after achieving endo- Anesth Analg 1995;81:408–10.tracheal intubation, tube obstruction can occur and both [12] Hussain A, Ahmad N. AB channa retrograde assistedsurgeon and anaesthetist should maintain vigilance [4]. This is fibreoptic intubation: an unusual but useful use of flexiblewell-demonstrated in this report where the ETT kinked fiberoptic endoscope. Internet J Anesthesiol 2004;8:2.intermittently, presenting intraoperatively as raised end-tidal [13] Hunt JA, Moisidis E, Haertsch P. Initial experience of integracarbon dioxide levels on capnography, ceasing when the scars in the treatment of post-burn anterior cervical neckwere completely released surgically. contracture. Br J Plast Surg 2000;53:652–8. [14] Tsai F-C, Samir M, Chen D-J, Yang J-Y, Hsieh M-S. The Following release of the contracture, many resurfacing classification and treatment algorithm for post-burnoptions exist but these are not within the scope of this paper. cervical contractures reconstructed with free flaps. BurnsWe opted for a dermal regeneration template in this case 2006;32:626–33.