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LETTERS TO EDITOR
Year : 2019  |  Volume : 13  |  Issue : 2  |  Page : 162-163

Emergency airway management in a child with malignant infantile osteopetrosis


Pediatric ICU, Children Hospital; Department of Anesthesiology and Intensive Care, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco

Correspondence Address:
Dr. Youssef Motiaa
Department of Anesthesiology and Intensive Care, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.SJA_746_18

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Date of Web Publication19-Mar-2019
 


How to cite this article:
Elbouaychi MA, Motiaa Y, Elkoraichi A, El Kettani SE. Emergency airway management in a child with malignant infantile osteopetrosis. Saudi J Anaesth 2019;13:162-3

How to cite this URL:
Elbouaychi MA, Motiaa Y, Elkoraichi A, El Kettani SE. Emergency airway management in a child with malignant infantile osteopetrosis. Saudi J Anaesth [serial online] 2019 [cited 2019 Jun 16];13:162-3. Available from: http://www.saudija.org/text.asp?2019/13/2/162/254568



Sir,

Osteopetrosis is a rare condition characterized by increased bone density caused by poor or deficient bone remodeling and osteoclast impairment.[1] There are multiple types of osteopetrosis. They may be distinguished by inheritance pattern: benign (autosomal dominant), intermediate (mild autosomal recessive), and infantile malignant osteopetrosis (autosomal recessive). The latter manifests in early childhood and has a poor prognosis.[2] Anesthetic management of malignant infantile osteopetrosis involves the management of several risks related to clinical manifestations and complications that might contribute to increased morbidity and mortality: neurologic and hematologic complications and airway difficulty.[3]

A 11-year-old boy was admitted to Pediatric Emergency Department due to respiratory failure, cyanosis, and severe bradycardia secondary to aspiration. Facial dysmorphism was obvious and he had low weight for age. Cardiopulmonary resuscitation (CPR) was started and 0.01 mg/kg intravenous adrenalin was administered. Insertion of a nasal tube was impossible and laryngoscopy was difficult because of limited mouth opening with small interincisor distance and also because there was a bone-like mass on the epiglottis obstructing the upper airway tract and bleeding on contact.

The patient was intubated after several attempts using Macintosh blade and then a Miller blade by a senior consultant, but a significant bleeding was noted.

Return of spontaneous circulation was achieved after 10 min of CPR. The patient was in sinus rhythm, the heart rate was 75 bpm, and the blood pressure was 75/45 mmHg. He was started on adrenalin infusion 0.2 μg/kg/min. Chest X-ray showed diffuse bone hyperdensity with fracture of the left third and fourth posterior rib arches [Figure 1].
Figure 1: Diffuse bone hyperdensity with fracture of the left 3rd and 4th posterior rib arches

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Past medical history included malignant osteopetrosis with failure to thrive, hepatosplenomegaly, blindness, deafness, and myelopathies requiring iterative blood transfusions; stem cell transplant being in its infancy.

The patient was treated for aspiration pneumonia. He developed a severe acute respiratory distress syndrome with septic shock. He died on day 6 of admission of refractory septic shock with multiple organ failure.

The primary problem in all forms of osteopetrosis or “marble bone disease” is an inability to effectively resorb and remodel bone.[4] The autosomal recessive variant or malignant infantile osteopetrosis is the most severe form with poor prognosis. Burt et al.[4] reported that osteopetrosis increases perioperative morbidity and mortality, which are primarily related to airway and respiratory problems. Multiple factors are associated to the high frequency of difficult airway in patients with malignant osteopetrosis.

They may have cranio-facial abnormalities such as proptosis, high-arched palate, broad facies, hypertelorism, frontal bossing, and mandibular hypoplasia.[5] Oral intubation may be more difficult if the movement of temporo-mandibular joint is diminished by the presence of mandibular osteomyelitis. Nasotracheal intubation can be difficult or even impossible due to the presence of bony encroachment on the nasal turbinates.[4]

In addition to these problems, hematologic complications of osteopetrosis are common. Thrombocytopenia is associated with high risk of profuse bleeding during laryngoscopy and even following a minor trauma. Outside emergency situations, these children are still at risk of episodes of desaturation during anesthetic induction because of reduced functional residual capacity due to hepatosplenomegaly causing cephalad displacement of diaphragm.[4]

To conclude, osteopetrosis is a complex disorder that increases the risk of difficult intubation and ventilation. The malignant type has poor prognosis and is associated with various pathophysiologic changes, which make airway management even more difficult in these children population.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Carvalho PH, Moura LB, Real Gabrielli MF, Cabrini Gabrielli MA, Antonio Pereira Filho V. Maxillary osteomyelitis associated with osteopetrosis: Systematic review. J Craniomaxillofac Surg 2018; 46:1905-10.  Back to cited text no. 1
    
2.
Batra P, Shah N. Recalcitrant osteomyelitis following tooth extraction in a case of malignant osteopetrosis. Int Dent J 2004; 54:418-23.  Back to cited text no. 2
    
3.
Jarineshin H, Fekrat F, Abadi MF. Anesthesia management of a child with osteopetrosis. Anesth Essays Res 2017;11:797-801.  Back to cited text no. 3
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4.
Burt N, Haynes GR, Bailey MK. Patients with malignant osteopetrosis are at high risk of anesthetic morbidity and mortality. Anesth Analg 1999;88:1292-7.  Back to cited text no. 4
    
5.
Wong ML, Balkany TJ, Reeves J, Jafek BW. Head and neck manifestations of malignant osteopetrosis. Otolaryngology 1978;86:585-94.  Back to cited text no. 5
    


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