Letters to the Editor: Letters & Announcements
To the Editor:
Treacher Collins syndrome (TCS) is characterized by maxillary, zygomatic, and mandible hypoplasia and known to be associated with difficult intubations (1,2). There has been no report about changes of the degree in difficulty in endotracheal intubation among growing children with TCS.
We reviewed the anesthesia records of a child with TCS who received seven consecutive operations during 15 years. The degree of difficult intubations was assessed with the following score: Grade 1, intubated within two attempts with conventional laryngoscopy; Grade 2, intubated more than two attempts with conventional laryngoscopy or the description of “difficult intubation” in anesthesia record; Grade 3, specific equipment and/or techniques (fiber-guided intubation, special designed laryngoscope, laryngeal mask airway, etc.) required. Grade 2 and 3 were regarded as difficult intubation. Intubations were performed by experienced pediatric anesthesiologists.
Results are summarized in Table 1. The operations he performed were as follows: canthoplasty at 2 years old, exodontias at 3 years old, otoplasty at the age of 7, 8, 9, and 10 years old, and osteotomy of mandibula at the age of 17. Grade 3 difficult intubation was not noted, however, the degree of difficulty in endotracheal intubation became severe with increasing age.
Craniofacial abnormalities often affect airway management. In pediatric patients, another complicating factor is growth, that is, how abnormalities change with growth. Airway abnormalities may change or remain the same as craniofacial structures mature (3). This communication showed that intubation for a patient with TCS becomes difficult with growth. The TCS is frequently associated with considerable difficulty in endotracheal intubation. On the other hand, it is not true that difficult intubation is encountered in every patient with TCS. These conflicting data regarding difficult airway in TCS may be partly caused by the differences in the stage of development.
While our case report may not apply to all patients with TCS, it is possible that the difficulty in intubation exaggerates along with growth in patients with TCS. Although previous anesthetic records are very available in planning airway management, patients with TCS must require reevaluation of the airway each time.
Gaku Inagawa, MD
Takaaki Miwa, MD
Koichi Hiroki, MD
Department of Anesthesia
Kanagawa Children’s Medical Center
1. Stone DJ, Gal TJ. Airway management. In: Miller RD, ed. Anesthesia. 5th ed. Philadelphia: Churchill-Livingstone, 2000:1414–51.
2. Palmisano BW, Rusy LM. Anesthesia for plastic surgery. In: Gregory GA, ed. Pediatric anesthesia. 4th ed. Philadelphia: Churchill-Livingstone, 2002:707–45.
3. Nargosian C. The airway in patients with craniofacial abnormalities. Pediatr Anesth 2004;14:53–9.