This case report describes securing the airway of an 11-year-old girl with extensive post-burn contractures of the neck, which had fused her chin, chest, and arms together. Initial attempts at awake fiberoptic intubation and direct laryngoscopy failed due to the distorted airway anatomy. A novel strategy was developed using a pediatric gastroscope to guide a wire into the trachea, followed by railroading an exchanger and endotracheal tube over the wire. This successful approach allowed for surgical release of the contractures and subsequent reconstructive procedures under general anesthesia. The report discusses challenges in managing such severe neck contractures and the collaborative effort needed between surgeons and anesthesiologists.

1. burns 36 (2010) e78–e81
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Case report
Securing the airway in a child with extensive post-burn
contracture of the neck: A novel strategy
Thai Er Wong a,*, Lay-Hooi Lim a, Wee Jin Tan b, Teik Hooi Khoo c
a
Department of Plastic and Reconstructive Surgery, Penang Hospital, Residency Road, 10990 Penang, Malaysia
b
Department of General Surgery, Penang Hospital, Residency Road, 10990 Penang, Malaysia
c
Department of Anaesthesiology and Intensive Care, Penang Hospital, Residency Road, 10990 Penang, Malaysia
article info
2. Case report
Article 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 posture
functional limitation, and optimal primary management can from increased thoracic kyphosis and airway examination
reduce the frequency and degree of deformity. Hence in the revealed a Mallampati Grade IV airway [7,8] with no clinically
developed world, severe contractures are uncommon but to discernible thyromental distance or neck extension. The
surgeons working in the developing world, whether perma- cervico-mental and the mento-sternal angles were completely
nently or as part of humanitarian missions, these clinical obliterated by thick stiff scars and the trachea was totally
scenarios continue to present themselves [1–5]. impalpable.
Perioperative airway management in these patients may Preoperative X-rays and CT scan to assess her airway
present serious challenges and consideration of related passage and related structures revealed a horseshoe-shaped
anaesthetic issues is necessary during surgical decision- passage taking an inverse U-turn from the oropharynx to the
making. 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 lignocaine
circumstances 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 distorted
number of options become much more limited due to the airway and her inability to tolerate the procedure after an
inability of the child to tolerate the manoeuvres required in initial phase of cooperation. Subsequently anaesthesia was
these techniques. We report a case of a child with severe burn induced using oxygen and sevoflurane via a Patil-Syracuse
contracture involving the neck, face, chest and shoulders mask (PS mask), an anaesthetic face mask which allows for
whereby, after initial failures, endotracheal intubation was passage of a bronchoscope cum endotracheal tube through a
finally achieved by means of a novel combined surgeon– capped port, but attempts at bronchoscopic intubation failed
anaesthetist 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 allow
advanced 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, a
warming 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 through
resulting 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 direct
only by withdrawal of the bronchoscope, closure of the port of vision and in rapid succession, the gastroscope was removed
the 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 exchanger
throughout which the mask was held in position with great after removal of the guide wire before a size 6 ETT was inserted
difficulty 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 an
the surface location of the trachea impossible, hence ruling acute turn with a slight kink causing brief spells of increased
out 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 by
lighted stylet was uniformly unsuccessful. The entire episode Integra1 resurfacing (Fig. 3). Endotracheal intubation for
lasted nearly 3 h. With increasing oedema of the oral subsequent surgical procedures was performed transorally
structures 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–e81
Fig. 2 – A sagittal section of CT scan of the head and neck revealing the horseshoe-shaped passage of the upper airway and
diagrammatic 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 part
equipment aids for tracheal intubation of the difficult airway, of the effort to accomplish a secure airway for surgery, from
a variety of options to secure the airway in the patient with providing a traction tongue suture to ensuring optimum
burn 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 extreme
traditional 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, shoulders
tissues in the region remain supple, straightforward intuba- and upper arms, in both vertical and transverse vectors. That
tion 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 the
contractures (atlanto-occipital extension of <20 degrees, patient presenting to us at age eleven years, was a significant
Mallampati Grades III or IV) successful intubation can be point in the history, alerting us to the observation that ongoing
achieved in 1–2 attempts in 79.5% of cases [5]. Failed unyielding deformational forces had been active for five years in
intubation attempts and multiple airway manoeuvres can a growing skeleton now reaching the growth spurt of
lead to traumatic airway complications, hypoxaemia and adolescence, and this was evidenced by the elongated mandible
apnoea, arrhythmias and laryngospasm, with possible cata- and the abnormal curvature of the spine. It was judged that with
strophic 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 the
surgeon 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 e81
identifiable, that the scars would require sharp division and because of extensive scarring in the previous skin graft donor
would 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 is
conventional 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 a
intubation that maintaining a mask seal was precarious, as the collaborative approach between surgeon and anaesthetist is
scars 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-round
stable grip on both mask and face. The repeated spells of oxygen
desaturation, together with the knowledge that ketamine has Conflict of interest statement
an ability to increase oral secretions which can in turn can lead
to laryngospasm, made it evident that if we were to attempt All authors have no conflict of interest in this case study and in
surgical release without intubation, surgeon and anaesthetist the preparation and submission of this manuscript. There are
would be competing intensely for the same severely restricted no financial and personal relationships with other people or
and distorted anatomical region, each obstructing the other organisations that could inappropriately influence (bias) their
from achieving their tasks safely, possibly leading to cata- work.
strophic failures for both. Hence the decision was made to aim
to achieve endotracheal intubation from the outset.
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