A difficult airway is a clinical scenario where an experienced clinician anticipates or encounters difficulty in establishing or maintaining a patent airway. This encompasses situations where tracheal intubation, the placement of a supraglottic airway, or both, are challenging. Difficult airways pose a significant clinical challenge for anesthesiologists, as they can lead to critical complications if not managed appropriately.
Identifying patients at risk for difficult airways is crucial for safe anesthetic management. The ASA 2022 guidelines [1] emphasize several risk factors that warrant special attention. These include obesity, limited neck mobility, prior history of difficult intubation, presence of facial or cranial abnormalities, and radiation therapy to the head and neck. Additionally, the presence of obstructive sleep apnea, known or suspected cervical spine instability, and a history of snoring are all pertinent factors that increase the likelihood of encountering a difficult airway.
In accordance with the ASA 2022 recommendations, a systematic approach is essential for managing difficult airways. This begins with thorough preoperative assessment and recognition of potential risk factors. Having an appropriate airway management plan in place is crucial. This may include the availability of advanced airway equipment and personnel with expertise in airway management.
During the induction of anesthesia, maintaining spontaneous ventilation, if possible, is advised. Techniques such as bag-mask ventilation and the use of supraglottic airways can be employed as first-line strategies. However, when faced with an anticipated or encountered difficult airway, the ASA recommends early involvement of an anesthesiologist with expertise in airway management and the consideration of a comprehensive strategy that may include video laryngoscopy, fiberoptic intubation, and surgical airway techniques. Furthermore, continuous monitoring and communication among the surgical team are paramount. Regular reassessment of the airway and readiness to transition to alternative techniques are crucial steps in ensuring patient safety.
In conclusion, understanding the definition, recognizing risk factors, and implementing a systematic approach for managing difficult airways are essential components of safe anesthetic practice in accordance with the ASA 2022 recommendations. By adopting a proactive approach and being well-prepared, anesthesiologists can navigate these challenging situations with confidence and ensure the best possible outcomes for their patients.
In the specific case of our patient, we were faced with an anticipated difficult airway due to Treacher Collins syndrome. Treacher Collins syndrome is characterized by impaired development of bone and soft tissues in the facial region. This autosomal dominant disorder is relatively rare, with an estimated incidence of 1 in 50,000 live births [3,4].
The most characteristic manifestations of this syndrome are micrognathia and deficient growth of the zygomatic arch, with no associated developmental delays [2–4]. The presence of micrognathia and potential obstruction in the hypopharynx can lead to significant respiratory challenges, sometimes reaching a critical level.
Consequently, individuals with Treacher Collins syndrome frequently undergo a series of surgical interventions aimed at rectifying facial irregularities and addressing the underdevelopment of facial structures.
In patients with Treacher Collins syndrome, the foremost anesthetic consideration revolves around the potential challenge of managing the airway.
Both mask ventilation and achieving visual access for endotracheal intubation can pose difficulties. Notably, the Cormack-Lehane grade, a widely used classification for laryngeal view during intubation, tends to deteriorate with age in individuals with Treacher Collins syndrome [2,5].
A comprehensive review of existing literature is crucial in establishing safety standards for airway management. A case study encompassing 240 patients with this syndrome across multiple institutions revealed that 40% of cases needed an alternative technique to secure the endotracheal tube, aside from direct laryngoscopy [5].
Diverse methods have been outlined for handling such cases. These encompass direct laryngoscopy, intubation utilizing a flexible fiberoptic bronchoscope, the light wand technique, the utilization of a laryngeal mask airway, employing the retrograde intubation approach, and, as a last resort, resorting to tracheotomy [6].
We anticipate encountering two more potential challenges during intubation: when it comes to dealing with a known difficult airway in pediatric patients who are awake, fiberoptic intubation poses a significant challenge, if not an impossibility, due to the inherent lack of cooperation in a sedated child. In addition, in our specific case, a nasal intubation was necessary to perform the surgical procedure, which was the placement of bimaxillary TMJ prostheses.
It is important to note that the patient provided written consent for the publication of this case report, and all personal details have been appropriately anonymized.