Tongue Flap Division in a Patient with Suspected Subglottic Stenosis Overcoming the Challenges in Airway Management: A Case Report

Background: Oronasal fistulae (ONF) can remain after surgery in some cleft palate patients. Repairing ONF requires surgery through the intraoral route, which may black the airway during the procedure. Tongue flap surgery is the surgical technique to fix ONF. The latter involves dividing and transplanting the tongue flap from the dorsal tongue to the palate, which can cause many challenges to the anesthesiologist.. This is particularly difficult as the nasal route cannot be accessed in pediatric patients undergoing general anesthesia for tongue flap division surgery. We present a challenging case of difficult airway management in a 6-year-old child with tracheal stenosis posted for tongue flap division surgery. Case Presentation: A 6-year-old male, 15 kg, diagnosed with bilateral cleft lip and cleft palate with tongue flap, was scheduled for tongue flap division and anterior palate fistula repair. Establishing an airway was difficult due to the presence of the tongue flap and a restricted mouth opening. Additionally, the patient had a previous difficult intubations due to subglottic stenosis, documented during anterior palate fistula repair conducted one month earlier. Inside the OT, standard monitors (NIBP, ECG, Pulse oximetry, and a temperature probe) were attached. We planned to perform fiberoptic intubation through the mouth. However, in our setup, the smallest size of ETT that could be loaded over pediatric fiberscope was 4.0 mm, as our institution does not have a neonatal fiberscope. As the previous anesthesia records during ONF repair with tongue flap showed possible intubations 3.5 mm cuffed ETT after the third attempt, we were left with no other option than to use an uncuffed size 4.0mm ETT via fiberscope. We were prepared for the potential challenges and informed the surgeons about alternative options if needed. After preoxygenation, the patient received intravenous (IV) glycopyrrolate 0.01 mg/kg, fentanyl 1 mcg/kg IVand a loading of dexmedetomidine 1 mcg/kg thereafter an infusion of 0.4 mcg/kg/hr IV. Topical anaesthesia was achieved intraorally with 2-3 puffs of 10% lignocaine spray. An uncuffed ET tube of size 4.0 mm was loaded on the fiberoptic scope. The senior consultant, an expert in FOB intubation, attempted oral intubation by gently passing the scope through the side of the tongue flap. Oxygenation was given through nasal prongs, and spontaneous ventilation was maintained. Once the glottic opening was visualized, the tip of the fiberscope was gently advanced and placed just proximal to the vocal cords. At this point, injections of propofol 30 mg and succinylcholine 30 mg were given. The fiberscope was advanced through the vocal cords, and the airway was secured. The surgery took 1 hour, during which the tongue flap was removed, and the palate repair was performed. The patient's recovery was uneventful. Conclusion: Comprehensive airway management plan should be sorted beforehand to avoid crisis. Intubation via an FOB offers an effective method to secure the airway in such challenging cases.