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LETTERS TO EDITOR
Year : 2023 | Volume
: 17
| Issue : 1 | Page : 125-126
Airway management in a child with large occipital encephalocele associated with restricted neck movements and receding mandible
Manbir Kaur, Rhythm Mathur, Arin Gopal Sarkar, Priyanka Sethi
Department of Anesthesia and Critical Care, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
Correspondence Address:
Manbir Kaur
Department of Anesthesia and Critical Care, All India Institute of Medical Sciences (AIIMS), Jodhpur - 342 005, Rajasthan
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sja.sja_463_22
| Date of Submission | 23-Jun-2022 |
| Date of Acceptance | 28-Jun-2022 |
| Date of Web Publication | 02-Jan-2023 |
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How to cite this article:
Kaur M, Mathur R, Sarkar AG, Sethi P. Airway management in a child with large occipital encephalocele associated with restricted neck movements and receding mandible. Saudi J Anaesth 2023;17:125-6 |
How to cite this URL:
Kaur M, Mathur R, Sarkar AG, Sethi P. Airway management in a child with large occipital encephalocele associated with restricted neck movements and receding mandible. Saudi J Anaesth [serial online] 2023 [cited 2023 Mar 31];17:125-6. Available from: https://www.saudija.org/text.asp?2023/17/1/125/364854 |
Sir,
Encephalocele is a congenital neural tube defect (NTD) in which a sac is formed outside the skull bone through a defect containing herniated intracranial contents (brain/meninges/cerebrospinal fluid).[1] An encephalocele is termed a “giant encephalocele” when its size is more than the head size.[2] NTDs are among the most common birth defects but in the last few decades, there has been a significant decline in the incidence of NTDs worldwide; however, the incidence is still much higher in developing countries.[3] The occipital bone is the most common site of encephalocele.[1],[2] This letter describes the airway management of a 3-year-old child with a large occipital encephalocele associated with restricted neck movement (neck being rotated to the left lateral position) and the receding mandible.
A 3-year-old male child, weighing 10 kg, was posted for surgical excision of a giant encephalocele. On preoperative evaluation, the child had soft, nontender swelling of 20 × 10 cm at the back of the head due to which the patient's head was tilted to the left side with restricted neck movements. The patient also had a receding mandible [Figure 1]a. The patient had a history of seizure episodes for 1 month for which he was on antiepileptics. A complete blood count revealed leucocytosis (12.79 × 103/μL) and low hemoglobin (8.7 g/dL). Other laboratory test results were unremarkable. The cardiac evaluation was normal to rule out any congenital anomaly. Two-dimensional echocardiography revealed normal functioning with an ejection fraction of 60%. Due to the large swelling on the back and restricted neck movement, we decided to secure the airway in the same position in which the child was lying. As he had a receding mandible also, so video-laryngoscope (C-mac)-guided intubation was planned. After premedicating the child with injection midazolam 0.02 mg/kg intravenously and fentanyl 1 mcg/kg, preoxygenation was done [Figure 1]b. Induction was done with propofol 2 mg/kg and injection rocuronium 0.6 mg/kg. Video laryngoscopy was performed, and the vocal cords were visualized (Cormack-lehane 2) [Figure 1]c. The trachea was intubated with a 4.5 mm cuffed endotracheal tube and secured adequately [Figure 1]d. Following this, the baby was placed carefully in the prone position. Intraoperatively, the child was monitored vigilantly. Anesthesia was maintained with O2/air, sevoflurane (0.1%–1%), and rocuronium infusion of 0.1 mg/kg/min. The surgical procedure went uneventfully. | Figure 1: (a) Child having giant encephalocele and receding mandible. (b) Position of the patient during bag-mask ventilation. (c) Video-laryngoscopy view of the glottis. (d) Patient position after securing the airway
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Though literature is available on the airway management of children with giant occipital encephalocele[4],[5] but in our case, we encountered a receding mandible which further added to the difficult intubation. Furthermore, there were restricted neck movements (the neck being rotated to the left lateral position); thus, there was no option available for making the head supine. Thus, we were only left with intubating the child in the lateral position (plan A). Hence, we opted for video-laryngoscope which helped in better visualization as well improved CL grade by 1. The child was successfully intubated in the first attempt. Our plan B was to place I-gel in the lateral position, in case the intubation attempt failed. A difficult airway cart was already kept available.
To conclude, in the case of a giant occipital encephalocele with a difficult airway having receded mandible and limited neck rotation, video-laryngoscope is a promising approach to intubating the patient with a difficult airway.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Markovic I, Bosnjakovic P, Milenkovic Z. Occipital encephalocele: Cause, incidence, neuroimaging and surgical management. Curr Pediatr Rev 2020;16:200-5.  |
| 2. | Ghritlaharey RK. A brief review of giant occipital encephalocele. J Neurosci Rural Pract 2018;9:455-6. [ PUBMED] [Full text] |
| 3. | Zaganjor I, Sekkarie A, Tsang BL, Williams J, Razzaghi H, Mulinare J, et al. Describing the prevalence of neural tube defects worldwide: A systematic literature review. PLoS One 2016;11:e0151586. |
| 4. | Goel V, Dogra N, Khandelwal M, Chaudhri R. Management of neonatal giant occipital encephalocele: Anaesthetic challenge. Indian J Anaesth 2010;54:477-8. [ PUBMED] [Full text] |
| 5. | Yιldιrιm ZB, Avci E, Torun F, Cengiz M, Cigdem A, Karabağ H, et al. Airway management for occipital encephalocele in neonatal patients: A review of 17 cases. J Neurosci Rural Pract 2011;2:159-61. |
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