Raghavendran Kalyanasundaram ·
Consultant Anesthesiology and Chronic Pain Management, Chennai, Tamil Nadu, India E-mail: raghavendranka@gmail.com
An 8 y old male child suffered from Crouzon syndrome, in whom intubation was perceived to be difficult, but extubation expected to be much more difficult. Crouzon syndrome is a genetic disorder characterized by the premature fusion of skull bones (craniosynostosis). This early fusion prevents the skull from growing normally and affects the shape of the head and face. This child had craniofacial operation in some other hospital when he was one year old and his postoperative period was uneventful. Owing to uncorrected mid facial hypoplasia along with shallow orbit, he had proptosis and was taken up for Le Fort3 osteotomy and insertion of RED2 (Rigid External Distractor) device, which was likely to remain in situ for a few weeks. RAE tube could be inserted without much of a problem, and the tube was changed to size 5.5 Kimberley Clarke tube using a tube exchanger at the end of surgery.
The surgery went on for nearly 6 h with full monitoring devices, including an A line, and his extubation was deferred till next day, for possible adjustment of device after seeing the X-ray picture. He was ventilated overnight with fentanyl, dexmedetomidine infusion, and was taken up for readjustment of the distraction device next morning.
GA was uneventful. But with the RED 2 device in situ, right nostril packed, left nostril occupied with Ryle’s tube, extubation was a real challenge.
Figure 1: Adequate mouth opening, but nostrils were blocked
Figure 2: Post op picture with device in situ
Figure 3: Picture prior to extubation
Figure 4: RED 2 device in situ