Journal of Indian College of Anaesthesiologists

: 2022  |  Volume : 1  |  Issue : 1  |  Page : 27--29

Anesthetic challenges in an infant with multiple structural airway anomalies

Preeti Goyal Varshney, Maitree Pandey, Garima Daga 
 Department of Anaesthesia and Intensive Care, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India

Correspondence Address:
Dr. Preeti Goyal Varshney
Department of Anaesthesia and Intensive Care, Lady Hardinge Medical College and Associated Hospitals, New Delhi


Airway anomalies such as laryngomalacia, laryngeal webs, micrognathia, and retrognathia cause respiratory distress in infants and pose a significant challenge in anesthetic management. We report the case of a 2-month-old infant with laryngomalacia on continuous positive airway pressure support since birth, posted for laryngeal surgery, who was found to have micro-retrognathia during pre anaesthesia checkup. Securing the airway and preventing hypoxia were the main challenges in this child. Adequate measures were taken for continuous oxygenation during induction of anesthesia. The child underwent supraglottoplasty with an uneventful intraoperative course. However, the airway obstruction persisted in the postoperative period requiring a surgical tracheostomy. The child subsequently underwent mandibular distraction surgery after 1 month and was discharged with a tracheostomy tube. Although various anesthetic options have been described to manage the difficult pediatric airway, the anesthetic technique should be customized to ensure airway patency and oxygenation in the perioperative period as illustrated in this case report.

How to cite this article:
Varshney PG, Pandey M, Daga G. Anesthetic challenges in an infant with multiple structural airway anomalies.J Ind Coll Anesth 2022;1:27-29

How to cite this URL:
Varshney PG, Pandey M, Daga G. Anesthetic challenges in an infant with multiple structural airway anomalies. J Ind Coll Anesth [serial online] 2022 [cited 2023 Feb 3 ];1:27-29
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Full Text


Airway anomalies such as laryngomalacia, laryngeal webs, tracheomalacia, retrognathia, and micrognathia can lead to respiratory distress in an infant.[1] Such child may have additional anomalies which make the anesthetic management more challenging in an already difficult pediatric airway. Some of these children may require repeat surgery presenting difficult challenges each time. The presented case report highlights the problems expected to be faced in such case and how we uniquely planned the management of anticipated problems.

 Case Report

A 2-month-old girl child, weighing 3 kg, diagnosed case of arthrogryposis multiplex congenita with a tentative diagnosis of laryngomalacia was scheduled for supraglottoplasty. Child had respiratory distress since birth and was on continuous positive airway pressure (CPAP) support of five cmH2O [Figure 1]. Various investigations such as karyotyping and echocardiography were already done to evaluate associated anomalies and were found to be normal. A written and informed consent from the parents was obtained after explaining the risks and consequences of anesthesia.{Figure 1}

General anesthesia was planned to preserve spontaneous respiration until sure to perform mask ventilation. In the operating room, monitors were attached and a size 8.0 FG infant feeding tube was placed nasally with its tip kept in the oropharynx. Injection glycopyrrolate 15 μg and fentanyl 5 μg were given intravenously. Sevoflurane in 100% oxygen was administered by mask while the patient was breathing spontaneously. As the plane of anesthesia deepened, the airway obstruction became more evident. An oropharyngeal airway was placed which relieved the obstruction, making bag and mask ventilation possible. The ENT surgeons decided to do a flexible fiberoptic laryngoscopy to confirm the diagnosis. Intermittent manual jet ventilation was done to supplement oxygen through the preplaced nasal infant feeding tube. Bulky collapsible arytenoids with large epiglottis and short aryepiglottic folds were visualized [[Figure 2]: Bulky arytenoids with short aryepiglottic folds]. Mask ventilation was resumed and injection succinylcholine 5 mg was administered intravenously. Apneic oxygenation was done through the nasal infant feeding tube while performing videolaryngoscopy. Optimal external laryngeal manipulation was required to view the glottis and an ETT of 3.0 mm ID was placed using a stylet. Surgical muscle relaxation was achieved with injection atracurium. Aryepiglottoplasty was completed successfully without any episode of hypoxia. The child was sent back to the pediatric intensive care unit for elective ventilation in view of laryngeal edema.{Figure 2}

Extubation was attempted after 48 h, but the child had respiratory distress which was not relieved with CPAP this time. Tracheostomy was performed in view of anticipated long-term ventilation requirement as the second planned mandibular distraction surgery was delayed due to ongoing COVID-19 pandemic. The tracheostomy tube (TT) in situ was replaced with a size 3.0 flexometallic tube following induction of anesthesia. It was again replaced with a TT after the completion of surgery. Neuromuscular blockade was reversed with the child breathing spontaneously. Rest of the postoperative course during the hospital stay was uneventful. The child was sent home with TT in situ. After 2 weeks, she was brought to the hospital in an unresponsive, cyanosed state and was declared brought dead.


Children with respiratory distress due to airway anomaly may have other associated anomalies.[2] A thorough preoperative evaluation is important to plan and provide safe anesthesia avoiding perioperative complications during surgery. Laryngomalacia and retromicrognathia, both make the airway management challenging with difficulty in bag mask ventilation (BMV) or intubation or both. The airway obstruction is at the level of glottis or below in laryngomalacia or tracheomalacia, which is not relieved by oro or nasopharyngeal airway (OPA/NPA). While in case of retromicrognathia,[3] OPA is helpful to relieve the airway obstruction during induction of anesthesia by lifting up the large tongue and soft tissue from the posterior pharyngeal wall to provide a patent airway. Since the child had laryngomalacia, we considered the possibility of failed BMV in spite of inserting an OPA, thus placed a nasal tube to provide the supplemental oxygen. This tube also proved helpful to provide oxygen while fiberoptic evaluation by surgeons.

Once a satisfactory BMV is confirmed, muscle relaxant can be administered to improve intubating conditions.[4] Visualization of glottis may not be possible due to structural malformation of mandible in retromicrognathia and due to floppy epiglottis in laryngomalacia. In anticipation of difficult laryngoscopy, succinylcholine was administered and oxygen was continuously insufflated through preplaced nasal tube to prevent hypoxia and allow more time during laryngoscopy.

The initial supraglottoplasty failed to relieve the airway obstruction and thus mandibular distraction surgery was planned. During the distraction surgery, TT was replaced with flexometallic ETT to take the anesthesia circuit away from surgical field as well as to provide IPPV. Changing the TT to ETT and back again in such a small child posed a constant threat of losing the airway. The child had an uneventful postoperative course at hospital but unfortunately died at home, possibly because of TT blockade or aspiration. A single sitting surgery possibly could have avoided the need for tracheostomy as it is known to be associated with frequent morbidity and occasional mortality.[5]


Careful planning of anesthesia technique to prevent hypoxia is mandatory in a child with multiple airway anomalies. Placing a nasopharyngeal tube before induction of anesthesia to provide supplemental oxygen can prove helpful in such cases. Management of TT is quite challenging as the tube change, blockade, and aspiration can pose significant threat to life.


This case report is written with the consent of the parents of the child.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parent(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patient's parents understand that their his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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