BACKGROUND AND OBJECTIVES: There are complex forms craniosynostosis, some of them featuring face and airway malformations, which may lead to difficult tracheal intubation (TI). This report aimed at presenting a difficult tracheal intubation case, in a child submitted to surgery for craniosynostosis correction. CASE REPORT: Child with 57 days of age, weighing 3700 g, cephalic perimeter 39 cm, physical status ASA II, with craniosynostosis, retrognathia, macroglossia, bilateral exophthalmus, inspiratory difficulty and mild intercostal retraction. In the supine position with a pad under the shoulders, the patient was pre-oxygenated, 10 mg propofol with 5 mg succinylcholine were injected and laryngoscopy was performed (straight blade number 1) without epiglottis visualization. Assisted ventilation was started and four new unsuccessful laryngoscopies attempts were performed. We decided for allowing spontaneous assisted ventilation and a new TI was attempted, also unsuccessful. Capnography showed no exhaled CO2. With the aid of a fibroscope, trachea was finally intubated, but the tube was too narrow and was replaced by a cuffed one. SpO2 was 98% but unstable, sometimes reaching 60%. P ET CO2 showed hypocapnia and irregular curve morphology. Auscultation revealed bilateral pulmonary ventilation, but the air was reaching the stomach as well. We suspected of a traumatic tracheal-esophageal fistula. Esophageal endoscopy showed that the tube was actually in the esophagus; since the cuff was inflated in the posterior edematous oral cavity, this would prevent air leakage and allow the tidal volume to ventilate stomach and lungs simultaneously. The tube was then properly introduced in the trachea, once again with the aid of the fibroscope, and surgery was performed. CONCLUSIONS: It is important to distinguish a simple craniosynostosis from those presenting face and airway malformations. Adequate TI equipment is mandatory and, in addition to basic monitoring, capnography is of great value to confirm tracheal intubation.
DISEASE, Neurologic: craniosynostosis; TRACHEAL INTUBATION
