A Combined Glidescope and Fiberoptic Technique for Nasotracheal Intubation in a Child with Treacher Collins syndrome

Background: The fiberoptic bronchoscope (FOB) is the “Gold Standard” for management of the difficult airway (DA) in both adults and children. Over the last decade, videolaryngoscopy (VL) has emerged as an important tool for airway management. FOB is technically challenging and may be extremely difficult in small children. VL, on the other hand, may also be unsuccessful despite an optimal view of the glottis. A combination of both devices is gaining popularity in DA management.

Case Report: A 2 yo AAM with Treacher Collins syndrome presented for dental restoration under general anesthesia. Physical examination findings were: dysmorphism, micrognathia, limited mouth opening and microtia. Following premedication with oral midazolam, inhalational induction with air/O2/sevoflurane mixture was performed and an IV line placed. A dexmedetomidine infusion was then started. A grade 3 view was obtained under direct laryngoscopy. A Glidescope size 2 blade obtained a grade 1 view and an oral tube was placed. Next, a nasotracheal tube was guided with a fiberscope to the glottis adjacent to the oral tube. The oral tube was withdrawn and the nasal tube advanced over the fiberscope into the trachea. The patient was extubated at the end of the procedure and discharged home from the PACU. This tube exchange technique required two attending anesthesiologists experienced in this technique

Conclusion: Hybrid (combined) techniques are gaining popularity in airway management as airway managers recognize the limitations of individual devices. We recommend that clinicians acquire skills in normal patients before using this device in complicated difficult airway cases.