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Difficult airway: An anesthesiologist’s nightmare

Mpoki M Ulisubisya, MD

CCBRT, P.O.Box 65588, Dar Es Salaam (Tanzania, E.A.); Phone: +255 75 5693324, +255 78 4693324E-mail: drmpoki@gmail.com; http://www.drmpoki.blogspot.com/

A 5 years old young boy with some obvious ENT malformations was referred to our newly commissioned hospital for a surgical intervention of his cleft palate. He had only one nostril and one ear on the right side. There was a small growth where the left ear would have been.

The procedure was to be carried out by a group of flying doctors from the African Medical Research Foundation (AMREF) based in Nairobi (Kenya), in one of their regular surgical camps in this part of the world. I was the only anesthesiologist posted to that hospital at the time, working with nurses that I had to train and supervise in the three operating rooms.

I was busy monitoring an infant under general anesthesia, when I was called by one of the two nurse anesthetists, trained by me and capable of doing long general and regional anesthesia lists with minimal help, to help with intubating the boy because according to them the ‘airway was very strange’.

I joined the team and looked inside the throat and their worries were confirmed; neither the epiglottis nor the vocal cords were visible; half of the soft and hard palate was missing. I tried with all the blades in the set but failed to intubate. All long this period, the child’s saturation was well maintained as we interrupted the attempts with episodic ventilation.

While pondering on what to do next, a surgeon came up and told me, “Sorry, I should have told you earlier, this patient was planned for this kind of surgery at the National Hospital a few weeks ago, but was postponed due to failed intubation”.

I thought of a bougie, but none was in sight for such a small human being.  I then improvised a neonatal urethral catheter stylet for an introducer and succeeded in pushing it through a very narrow anatomical orifice in the larynx leading to what I believed was the opening at vocal cords to the trachea, threaded over it my armored 3.5mm endotracheal tube and by God’s grace into the trachea I went. Capnography vindicated my successful intubation!

This would have been the happy ending to a challenging situation, unfortunately it was not! Just before the cleft was repaired, the surgeon packed the throat with a wet gauze and then proceeded with the surgery. At the end of the good work, she inspected for any obvious bleeders, and got the conviction that all was dry and pink. The anesthetic gases had been turned low except for oxygen, the boy was breathing spontaneously without any struggle.  She then decided to pull out the packed gauze. To my horror the tube too got pulled out!!