JBUR-4614; No.

of Pages 9

burns xxx (2015) xxx–xxx

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier.com/locate/burns

Review

Airway management in patients with burn

contractures of the neck

Smita Prakash *, Parul Mullick

Department of Anesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjang Hospital,
New Delhi, India

article info abstract

Article history: Airway management of patients with burn contracture of the neck (PBC neck) is a challenge
Accepted 17 March 2015 to the anesthesiologist. Patient evaluation includes history, physical and airway examina-
tion. A safe approach in the airway management of a patient with moderate to severe PBC
Keywords: neck is to secure the airway with the patient awake. The anesthesiologist should have a pre-
Burn neck contracture planned strategy for intubation of the difficult airway. The choices advocated for airway
Difficult airway management of such patients include awake fiberoptic-guided intubation, use of intubating
Difficult intubation laryngeal mask airway, intubation without neuromuscular blocking agents, intubation with
neuromuscular blocking agents after testing the ability to ventilate by mask, pre-induction
neck scar release under local anesthesia and ketamine or sedation followed by direct
laryngoscopy and intubation and video-laryngoscope guided intubation, amongst others.
Preparation of the patient includes an explanation of the proposed procedure, sedation,
administration of antisialogogues and regional anesthesia of the airway. The various
options for intubation of patients with PBC neck, intraoperative concerns and safe extuba-
tion are described. Back-up plans, airway rescue strategies and a review of literature on this
subject are presented.
# 2015 Elsevier Ltd and ISBI. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
2. Patient evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3. Classification of PBC neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
4. Pre-planned strategy for airway control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
5. Patient preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
6. Sedative and adjuvant medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
7. Local anesthetic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
8. Topical anesthesia of the airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
9. Nerve blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

* Corresponding author at: C 17 HUDCO Place, New Delhi 110049, India. Tel.: +91 011 26253523.
E-mail addresses: [email protected] (S. Prakash), [email protected] (P. Mullick).
http://dx.doi.org/10.1016/j.burns.2015.03.011
0305-4179/# 2015 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: Prakash S, Mullick P. Airway management in patients with burn contractures of the neck. Burns (2015), http://
dx.doi.org/10.1016/j.burns.2015.03.011
JBUR-4614; No. of Pages 9

2 burns xxx (2015) xxx–xxx

10. Awake fiberoptic-guided intubation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

11. Supraglottic airway devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
12. Direct laryngoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
13. Video-assisted laryngoscope and video-assisted intubating stylet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
14. Succinylcholine, rocuronium and sugammadex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
15. Tumescent anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
16. Back-up plans for airway management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
17. Airway rescue strategies in PBC neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
18. Difficult pediatric airway due to PBC neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
19. Know when to stop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
20. Intraoperative concerns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
21. Extubation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
22. Review of case-series. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
23. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

1. Introduction information about airway management [1]. The airway of a

burn patient progressively becomes more difficult with time as
Airway management of patients with burn contracture of the neck contracture worsens.
neck (PBC neck) requires skill and competency. The airway The airway examination assesses anticipated difficulty
may be difficult for one or several of the following reasons: with ventilation, intubation, or both [1]. Some airway assess-
restricted mouth opening (cicatrized angles of the mouth), ment parameters useful in evaluation of a difficult airway are
obliterated nasal passages, decreased oropharyngeal space, not applicable in PBC neck patients. Classical Mallampati test
fixed flexion deformity of the neck, limited atlanto-occipital is performed with the head in neutral position; in PBC neck
joint extension, reduced submandibular space compliance or this assessment (visibility of oropharyngeal structures) is
altered tracheal position. The fixed flexion deformity results in possible only in the flexed neck position. Thyromental
nonalignment of the oral, pharyngeal and laryngeal planes for distance and ability to protrude the mandible are impossible
intubation. In a patient undergoing multiple surgical proce- to precisely measure though a rough estimate of sternomental
dures, release of the neck contracture is performed first so as distance is possible. Airway features such as the interincisor
to ensure easier airway control in subsequent surgeries. distance (<3 cm), Mallampati class (>2), sternomental dis-
Several methods of management of airway difficulties in this tance (<12 cm), range of neck movement <808, limitation of
patient population exist that are chiefly governed by institu- head extension and submandibular space compliance signify
tional practice or personal preference. A literature search did a difficult airway [1]. A non-compliant submandibular space
not reveal previous articles that provide a comprehensive prevents compression of the tongue during laryngoscopy,
review of this subject. In this article, patient evaluation, resulting in an anterior larynx. Traction forces caused by scar
strategies for airway management, intraoperative problems contracture may also pull the laryngeal structures anteriorly
and concerns at extubation of patients with PBC neck are or laterally. Nasal patency should be checked. Neck X-ray
considered. The information is based primarily on data from (antero-posterior and lateral views) provides useful informa-
published randomized clinical trials and case reports which tion about naso- or oro-pharyngeal space, deviation of the
were identified through Pubmed, Medline and Google Scholar larynx or trachea and airway compression.
databases. We also used our personal experience of practice.
Search terms used included ‘‘post burn’’, ‘‘neck’’, ‘‘contrac-
ture’’, ‘‘anesthesia’’, ‘‘airway’’, ‘‘difficult airway’’, ‘‘difficult 3. Classification of PBC neck
intubation’’. It is hoped that this review will provide clinicians
with an understanding of the anesthetic aspects of airway Onah [2] has described a clinical classification system for post-
management in patients with PBC neck. burn mentosternal contractures comprising four major groups
based on the location of the contracting band and extent of
flexion or extension away from the anatomical position of the
2. Patient evaluation neck and jaws. Each group is further sub-classified based on
the contracting segment width. Jeong et al. [3] modified the
Patient evaluation comprises history, physical and airway Onah classification (Table 1) and found significant correlation
examination [1]. A history of the cause of burns (thermal, between modified Onah class 2b and 3 and Cormack grade 3
chemical or electrical), time (duration) and previous surgery and 4 laryngoscopic views (sensitivity and specificity 86.0%
under anesthesia should be obtained. History of snoring may and 84.9%, respectively). The application of the modified Onah
indicate difficult mask ventilation following induction of class can reduce the frequency of an unanticipated failure to
anesthesia. History of inhalational injury may suggest visualize laryngeal structures and potential unnecessary
tracheal stenosis that may hamper tracheal tube placement. interventions related to over-prediction of airway difficulty
Previous anesthesia records, if available, may yield useful in patients with post-burn mentosternal contractures [3].

Please cite this article in press as: Prakash S, Mullick P. Airway management in patients with burn contractures of the neck. Burns (2015), http://
dx.doi.org/10.1016/j.burns.2015.03.011
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Table 1 – The modified Onah classification [3]. 2 mg/kg) that results in a calm, comfortable and cooperative
Type Degree of contracture patient. Dexmedetomidine, a highly selective alpha-2 adren-
ergic receptor agonist, is a useful adjunct for awake intubation
1 Mild anterior contracture: the patient is able to flex
because of its sedative, analgesic, and anxiolytic properties
the neck and bring the neck and jaws to the
anatomical position while erect without respiratory depression [8]. A loading dose (1 mg/kg
(a) Narrow, <2 finger breadths over 10 min) provides procedural sedation for fiberoptic
b) Broad, >2 finger breadths nasotracheal intubation [9]. Glycopyrrolate (an antisialogogue;
2 Moderate anterior contracture: attempts at 0.2 mg IV), by decreasing oral secretions, aids in the placement
extension away from the anatomical position result and effectiveness of topical agents and provides an unobs-
in a significant pull at the lower lip
cured view. The patient should be given anti-aspiration
(a) Narrow, <2 finger breadths
(b) Broad, >2 finger breadths
prophylaxis with ranitidine (50 mg IV) and metoclopramide
3 Severe anterior contracture: the patient’s neck is (10 mg IV). Oxymetazoline (0.05%) drops are instilled prior to
contracted in the flexed position and the chin is nasal intubation to shrink the nasal mucosa and decrease
occasionally restrained down to the anterior trunk bleeding. Topical benzocaine is no longer recommended due
The patient is unable to reach anatomical position of to the risk of methemoglobinemia.
the neck and jaws

7. Local anesthetic
4. Pre-planned strategy for airway control
Lignocaine (1–4%) is most commonly used for airway
A pre-planned strategy for airway control should be formu- anesthesia for awake intubation. It is important to be
lated and discussed with other anesthetic team members. cognisant of the amount of lignocaine used (toxic plasma
Each team member should be clear about his/her role. The levels >5 mg/ml) as it is quickly absorbed from the oral and
strategy could include intubating the trachea with the patient tracheal mucosa. Total lignocaine dose should be limited to
awake or after induction of general anesthesia, with or without 8.2 mg/kg [10]. Use of such high doses of lignocaine is safe as
neuromuscular blocking agents [1]. It is essential to have a back- the drug is administered in fractional doses at different sites in
up plan for airway management in the event of failure of the the airway over a period of time.
primary plan. Awake intubation has been advocated as the
safest technique to secure the airway in a cooperative patient
for a difficult airway [1,4] and this applies to patients with PBC 8. Topical anesthesia of the airway
neck. The advantages include patient cooperation, spontane-
ous breathing and the ability to maintain airway patency [5]. Topical anesthesia is the mainstay of airway preparation in PBC
Induction of general anesthesia, with or without neuromuscu- neck and can be achieved by use of aerosol sprays, nebulization,
lar blocking agents (NMBAs), causes the soft palate, tongue and gargling or spray-as-you-go technique (SAYGO). Nebulization
epiglottis to approximate to the posterior pharyngeal wall [6]. involves inhalation of vapour (4 ml of lignocaine 4%) through
This decreases the oropharyngeal airspace available for the nose or mouth for nasal or oral intubation, respectively.
maneuvering the tip of the fiberscope to locate the glottis [7]. Cotton-tipped nasal pledgets soaked in 2–4% lignocaine are
An additional experienced anesthesiologist should be available placed (for 15 min for optimal effect). Alternatively, 2%
for assistance [1]. The difficult airway cart should be checked. lignocaine jelly can be squeezed into each nostril and the
Surgeons should be scrubbed in the operating room to release patient is asked to sniff vigorously. The patient is instructed to
the contracture or to provide an emergency surgical airway, if gargle with viscous lignocaine 2%. The solution is expectorated
required, without delay. to avoid excess local anesthetic absorption. In the SAYGO
technique, the fiberscope is advanced in the hypopharynx
where the glottic structures are visualized. Lignocaine 2%
5. Patient preparation solution (1 ml lignocaine and 9 ml air drawn in a 10-ml syringe)
is injected via the working channel of the fiberscope on the
An explanation of the proposed airway management tech- mucosa. Alternatively, an epidural catheter (introduced
nique during preoperative evaluation allays patient fears and through the side port) can be threaded out of the end of the
improves patient cooperation. The patient should be reas- scope and lignocaine injected onto the cords. The catheter can
sured that discomfort will be minimized by administration of also be placed through the cords allowing a further dose to be
sedatives. The patient (and/or responsible person) is informed injected below the cords. The SAYGO technique is particularly
about the risks associated with the anesthetic management of useful in patients with PBC neck as it is usually not possible to
the difficult airway. Written informed consent is obtained perform nerve blocks to anesthetize the upper airway.
when possible.

9. Nerve blocks
6. Sedative and adjuvant medications
Superior laryngeal and translaryngeal nerve blocks are usually
Sedation may be provided by judicious use of small doses of not possible in PBC neck due to lack of access to the anterior
benzodiazepine (midazolam 0.03 mg/kg) and opioid (fentanyl and lateral neck, hyoid bone and limited or no neck extension.

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4 burns xxx (2015) xxx–xxx

(3) extension maneuver [27] (pulling the handle of the ILMA back
10. Awake fiberoptic-guided intubation toward the operator); (4) Chandy maneuver [27] (this maneuver
consists of two sequential steps). The first step enables optimal
In PBC neck location of the glottis and insertion of the fiberscope alignment of the laryngeal aperture and the bowl of the mask.
into the trachea can be difficult because of the fixed flexion The metal handle is used to rotate the device in the sagittal
deformity of the neck and distortion of upper airway structures plane to establish optimal ventilation with minimal resistance
by the fibrotic scar. Maneuvers that facilitate glottis visualiza- to bag ventilation and minimal audible leaks during manual
tion, such as jaw thrust and head extension may not be possible ventilation. In the second step, just before blind intubation the
in such patients. Sometimes, because of extreme flexion LMA-Fastrach is slightly lifted (but not tilted) away from the
deformity of the neck, it may be very difficult or even impossible posterior pharyngeal wall using the metal handle. This
to advance the tracheal tube over the scope into the trachea facilitates the smooth passage of the ETT into the trachea; (5)
when the fiberscope has been successfully placed in the change of size of ILMA.
trachea. An important reason for this difficulty is deviation of In patients with extreme flexion of the neck with the mouth
the course of the tube from that of the fiberscope toward the opening directed inferiorly, it may not be possible to introduce
epiglottis, arytenoids cartilage, pyriform fossa or esophagus the ILMA in the conventional manner. The hypotenuse of the
[7,11,12]. Oesophageal intubation may occur despite correct triangle formed on joining the tip of the mouth portion with the
placement of the fiberscope into the trachea [13,14]. machine end of the ILMA is the minimum distance required
To overcome difficulty with railroading (advancing a between the hard palate and the most anterior part of the
tracheal tube over a fiberscope) the tube, the following is patient’s chest for successful ILMA placement [28]. Kumar et al.
recommended: reducing the gap between the fiberscope and [28] advocate the 1808 rotation technique (or upside-down
trachea, use of flexible tube and 908 anti-clockwise rotation of technique) of introducing the ILMA in such patients; the ILMA is
the tracheal tube [7]. Compared to a polyvinyl chloride (PVC) held such that the machine end and the superior surface of the
tube, a flexible tracheal tube is easier to advance over the handle faces cephalad and once the mask portion is inside the
fiberscope as it can change direction more easily to follow the mouth up to its angulation, the ILMA is rotated through 1808 to
course of the fiberscope [15–17]. Warming a PVC tracheal tube lie in its regular position. A patient with severe neck contracture
is not recommended in PBC neck. A warm PVC tracheal tube is and two finger mouth opening was successfully managed using
softer and hence more likely to get kinked in the acutely the 1808 rotation technique of ILMA insertion under sevoflurane
angled naso- or oro-pharynx of the patient with extreme inhalational anesthesia with spontaneous breathing [29].
flexion deformity of the neck [18]. Fiberoptic-guided tracheal intubation through an ILMA
For oral intubation, airway intubators such as the Berman may not be straight forward in patients with PBC neck; some
[19], Ovassapian [20] and Williams [21] are available. However, degree of side-to-side ILMA manipulation may be required for
in patients with microstomia (cicatrisation following oral glottis visualization through the fiberscope. Following tracheal
burns), these airways may not be accommodated through the intubation through the ILMA, removal of the ILMA with use of
narrowed inter-incisor gap. The cut barrel of a 10-ml syringe has the stabilizer rod has to be performed with utmost care to
been used as a bite-guard during oral awake fiberoptic-guided avoid accidental extubation. Pushing the tracheal tube further
tracheal intubation in a patient with limited mouth opening into the trachea before attempting removal of ILMA can help
[22]. A patient with obliterated nares, extreme microstomia and prevent inadvertent extubation [28]. At times it might be
severely limited neck extension was managed by awake oral prudent to leave the ILMA and tube in place until after the
fiberoptic-guided intubation aided by a Williams airway contracture has been released [28].
intubator [23]. Assessing the correct airway-intubator size is The Laryngeal Mask Airway (LMA) has a role in the
important. The measured length from the lips to the back of the management of the difficult airway as a definitive airway or
tongue on lateral neck X-ray was used to determine the airway as an aid to tracheal intubation, either blindly or with fiberoptic
size [23]. A similar patient was managed by awake oral fiberoptic guidance. Blind passage of a tube exchanger or a bougie into the
intubation aided by Berman’s airway that allows the tracheal trachea can be attempted followed by removal of the LMA and
tube to pass directly through its channel into the glottis [24]. intubation with a tracheal tube over the guiding device [27]. The
LMA can be used successfully as a bridge to restore the airway in
a cannot ventilate cannot intubate (CVCI) situation [3]. Howev-
11. Supraglottic airway devices er, the LMA may not always be correctly placed because of
anatomical abnormalities and may be displaced by intraoper-
The Intubating Laryngeal Mask Airway-FastrachTM (ILMA) can ative position changes [30]. Other supraglottic devices such as
be used for ventilation and to facilitate either blind or fiberoptic- the ProSeal LMA, I-gel and laryngeal tube may be similarly used.
guided tracheal intubation. In patients with PBC neck in whom A Combitube was successfully used in a patient with PBC neck
face-mask ventilation is expected to be difficult, the ILMA may with limited mouth opening and tracheal stenosis that
be inserted after topical anesthesia of the upper airway. If precluded tracheal intubation [31].
intubation through the ILMA is unsuccessful, the following
maneuvers may be performed; (1) up-down maneuver (slowly
withdrawing the inflated cuff from the pharynx 5–6 cm and 12. Direct laryngoscopy
then reinserting it [25] which repositions a down-folded
epiglottis during blind ILMA use); (2) optimization maneuver Intubation by direct laryngoscopy is practiced when mask
[26] (adjusting the ILMA position until optimal seal is obtained; ventilation is expected to be satisfactory following induction

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of anesthesia (intravenous or inhalational) and intubation is patient is mobile which may take well over 1–2 years in
expected to be difficult but possible. Preoxygenation is patients with major burns [37]. If immobilization persists
important [1]. In cases where difficulty is anticipated, because of severe contractures, the up-regulation will not be
intubation or laryngoscopy is performed without use of abated. Use of succinylcholine in this phase can result in life-
neuromuscular blocking agents. The combination of fentanyl threatening hyperkalemia. Rocuronium (0.9 mg/kg) can be
(2 mg/kg) and midazolam (0.03 mg/kg) followed 5 min later by used for rapid tracheal intubation in situations where
propofol (2.5 mg/kg) provides acceptable intubating condi- succinylcholine is contraindicated.
tions in a majority of patients [32]. If intubation is judged to be Sugammadex, a modified gamma-cyclodextrin, rapidly
easy, (favorable Cormack grade), neuromuscular block can be and completely reverses the neuromuscular block associated
provided by rocuronium 0.9 mg/kg. External laryngeal manip- with rocuronium by encapsulating it in the plasma in a 1:1
ulation, use of a smaller than regular sized tracheal tube, ratio [38]. At a dose of 16 mg/kg, it can reverse profound
stylet, bougie and McCoy laryngoscope blade can facilitate neuromuscular block produced by rocuronium (1.2 mg/kg) in
intubation. The use of a two-person intubation technique is less time than it takes to recover from succinylcholine (1.5 mg/
particularly useful in this setting, wherein, one anesthesiolo- kg) [39,40]. Therefore, it has a potential role as a rescue drug in
gist performs laryngoscopy and optimal laryngeal manipula- a CVCI situation after administration of rocuronium by
tion to obtain the best possible view of the glottis and a second restoring spontaneous ventilation and hence allowing awak-
anesthesiologist intubates the trachea. In case of unilateral ening of the patient. However, the CVCI scenario is often
scars, the epiglottis and vocal cords are pulled toward the side multifactorial (airway edema and bleeding due to repeated
of the scar and the laryngoscope should be advanced attempts at intubation, use of sedatives and residual effect of
ipsilaterally toward the direction of the scar [30]. Use of a induction agent) and reversing muscle relaxation alone may
lightwand in patients with PBC neck is hampered by thick scar not guarantee the ability to rescue the CICV scenario [41].
tissue that may obscure light and result in esophageal
intubation.
15. Tumescent anesthesia

13. Video-assisted laryngoscope and video- Tumescent anesthesia (TA) involves subcutaneous infiltration
assisted intubating stylet of a large volume of very dilute lignocaine (as low as 0.05% or
0.1%) and adrenaline (1:200,000). This allows administration of
Video-assisted rigid laryngoscopy or video laryngoscopy (VL) is up to 55 mg/kg of lignocaine [42]. TA has been used safely for
a useful adjunct to facilitate tracheal intubation in patients harvesting skin grafts, liposuction and PBC neck release.
with PBC neck. While direct laryngoscopy is associated with Factors that contribute to the safety of TA include dilute
failure when a laryngeal view cannot be obtained, VL solution of lignocaine, a relatively avascular subcutaneous/
frequently overcomes this obstacle. However, difficulties fibrous tissue, lipid solubility of lignocaine, vasoconstrictive
may be encountered in advancing the tracheal tube toward effect of adrenaline and compression of vasculature from
the laryngeal view of the video-monitor. This disadvantage infusion of a large volume of solution [43]. The solution is
can be overcome by using fiberoptic bronchoscopy as a infiltrated along the incision line and into the surrounding
guidewire under VL view [33]. Park et al. [33] performed awake tissues. Safe and quick surgical neck contracture release
fiberoptic intubation under VL guidance following release of facilitates tracheal intubation. Neck contracture release prior
neck contractures under local anesthesia in a patient with to intubation was first described by Tanzer [44] in 1964 who
severe mentosternal contracture. Shehata et al. [34] found suggested release of the inferior half of the neck under local
time to intubation to be shorter with VL compared with anesthesia when difficulties are anticipated. Further release
fiberoptic intubation in 17 patients with PBC neck. However, can then follow successful intubation. The interval between
they reported that two patients underwent contracture release incision and tube insertion may be rather critical. The use of
under local anesthesia for intubation and two other patients TA following premedication with diazepam 0.1 mg/kg IV,
were operated under general anesthesia via LMA. Ali et al. [35] pentazocine 0.6 mg/kg IM and glycopyrrolate 0.004 mg/kg IV
reported successful airway management of five patients with for release of PBC neck has been described [45].
severe PBC neck using the Airtraq optical laryngoscope. The
smaller diameter of the video-assisted intubating stylet is
useful in patients with markedly limited mouth opening 16. Back-up plans for airway management
where VL cannot be introduced [36].
There are occasions when a planned gold-standard awake
fiberoptic-guided intubation may fail. Back-up plans include
14. Succinylcholine, rocuronium and ILMA-guided tracheal intubation or use of LMA. Surgical release
sugammadex of the neck contracture (and/or microstomia) using ketamine,
with or without local anesthetic infiltration, followed by direct
Thermal injury is associated with up-regulation of acetylcho- laryngoscopic intubation, ILMA-guided intubation or LMA is an
line receptors (AChRs) that spread throughout the muscle option after a failed fiberoptic intubation attempt [46]. An
membrane because of inflammation, local denervation of elective surgical release of the neck contracture prior to
damaged muscle, or both. AChRs return to normal levels when intubation may be safely performed following induction in an
wounds are healed, protein catabolism has subsided and the anesthetised, spontaneously breathing patient directly after the

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first failed intubation attempt at direct laryngoscopy. Alterna- anesthetic during FOI. In case the fiberscope is too large for
tively, the case may be postponed and rescheduled at a later the child’s trachea, a guidewire may be passed through the
date. Where resources are limited, challenges due to fixed suction port to facilitate intubation. As in adults, the LMA can be
flexion deformities could be overcome by use of ketamine, a useful adjunct in pediatric FOI. In burn contractures causing
inhalational anesthesia and LMA before contracture release severe neck flexion, surgical release of the contracting fibrotic
[47]. It may be noted that any of these back-up plans may be the tissue may be performed under ketamine sedation and local
primary anesthetic plan in place with limited resources. anesthetic infiltration followed by conventional tracheal
Oza et al. [48] describe the anesthetic management of a intubation. If repeated intubation attempts lead to airway
patient with PBC neck (fixed flexion deformity, microstomia) edema, dexamethasone 0.25 mg/kg IV is administered. Awake
by a combination of tumescent anesthesia, ketamine and extubation is recommended with a pre-formulated extubation
conventional laryngoscopic intubation with the aid of a stylet plan in place.
after a failed fiberoptic intubation. Intubation with a gum-
elastic bougie failed due to fixed epiglottis and anterior larynx.
The stylet was bent to an angle of 908, at a distance from the tip 19. Know when to stop
approximately conforming to the distance between the tragus
and the thyroid cartilage [48]. A case of severe PBC neck with It is equally important to realize when to abandon multiple
limited mouth opening was managed by up-side down attempts at intubation. Repeated intubation attempts of
technique of AMBU LMA insertion when the primary plan of inserting a fiberscope into the trachea, advancing the tracheal
fiberoptic-guided tracheal intubation under inhalational an- tube over the fiberscope or direct laryngoscopy can result in
esthesia failed because of equipment malfunction [49]. Jasper injury to the larynx and surrounding tissues that can cause
[50] reported a 13-year-old girl with sternomental contractures bleeding and upper airway edema. Complete airway obstruc-
and cicatrized angles of the mouth scheduled for contracture tion can occur during multiple attempts at intubation even
release. Direct laryngoscopy following inhalational induction when the patient is not anesthetized. During airway emer-
(halothane in 100% oxygen) revealed a Cormack grade 4 view gencies, persistent intubation attempts were associated with
and an LMA was impossible to insert. The surgeon was asked death or brain damage [52].
to incise the mentosternal scar tissue. This improved the
Cormack grade to 3 and a size 3 LMA was easily inserted and
surgery performed [50]. 20. Intraoperative concerns

The patient is positioned with a sandbag or roll under the

17. Airway rescue strategies in PBC neck shoulder. Initially two or more head rings/pillows may be used
to support the head. As the surgeon releases the contracture,
Unlike other difficult airways, rescue oxygenation strategies the rings are removed one at a time. An important practical
such as cricothyroid puncture or creation of a surgical airway, point to remember is that as the contracture is being released,
may be impossible in PBC neck because the neck anatomy is a tracheal tube fixed to ensure bilateral air entry to the lungs
grossly distorted and concealed by the thick scar. Supraglottic when the neck is acutely flexed, may need to be pushed
airway devices have an important role in rescuing the airway. further into the trachea to avoid accidental extubation as head
In an emergency, a quick incisional release of the contracture extension is achieved. Attention should be paid to appropriate
is an effective method to ensure maintenance of a clear airway fixation of the tracheal tube as the head is out of sight under
and to facilitate successful intubation in the anesthetised the drapes and to guard against tracheal tube disconnection,
patient. If this fails, emergency tracheotomy will be required. kinking or obstruction.
Waymack et al. [51] reported 17 emergency neck contracture
release procedures in 13 patients with PBC neck; failure to
intubate despite contracture release in four instances was 21. Extubation
managed by emergency tracheostomy.
Following surgery, the patient lies supine with the head in
extension and a bulky neck dressing that can make reintuba-
18. Difficult pediatric airway due to PBC neck tion difficult despite release of the contracture. Some surgeons
place a plaster of paris neck cast to ensure that the neck
The techniques used in adult patients need to be modified for a remains in extended position postoperatively. The trachea
child with a PBC neck. Adequate topical airway anesthesia, should be extubated when the patient is awake [1]. There
sedation, rapport and gentleness are the keys to successful should be an airway management plan that can be imple-
awake fiberoptic intubation (FOI) in the older child. For smaller mented in case the patient is unable to maintain adequate
children with burn contractures or in an uncooperative older ventilation after extubation. Short term use of a tube
child, inhalational induction technique is recommended. exchanger that can serve as a guide to expedite re-intubation
Inhalational induction with a FiO2 of 1.0 enhances safety. should be considered in cases where difficult intubation
Ketamine (0.2–0.8 mg/kg IV over 2–3 min), supplemented by persists [1]. The airway exchange catheter (AEC) can also serve
local anesthetic nebulization, is commonly used to maintain as a conduit to administer oxygen (insufflations, manual or jet
spontaneous respiration during FOI. Alternatively, a nasopha- ventilation) [1] that can provide time to use alternative airway
ryngeal airway may be used to administer inhalational management strategies such as a fiberoptic bronchoscope or

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Table 2 – Number of intubation attempts, intubation time and complications in PBC neck.
Group 1 (n = 1375) Group 2 (n = 308)
Atlanto-occipital extension >208 <208
Mallampati class I/II III/IV
Anesthetic technique Intravenous induction TIVA/sevoflurane
Breathing Controlled Spontaneous
Equipment Macintosh laryngoscope FOSL
Intubation attempts, n (%)
First attempt 1279 (93) 114 (37)
2 or 3 attempts 96 (7) 156 (50.6)
4 or >4 attempts 0 (0) 38 (12.3)
Intubation time <3 min 1300 (94.5) 123 (39.9)
Traumatic complications 45 (3.2) 44 (14.3)
Laryngospasm, n (%) 0 (0) 4 (1.3)
Hypoxemia (SpO2 < 90%) 0 (0) 11 (3.6)
Cardiac arrest or brain damage 0 (0) 0 (0)

Adapted from Xue et al. [54].

TIVA, total intravenous anesthesia; FOSL, fiberoptic stylet laryngoscope. Values are n (%).

surgical airway. Excessive depth of insertion increases the risk skilled assistance, expertise and gentle handling of the
of tracheo-bronchial tree perforation and barotrauma with jet difficult airway. The strategy of airway management will
ventilation [53]. If re-intubation is necessary, a laryngoscope depend on the skills and preferences of the anesthesiologist.
should be used to facilitate passage of the tracheal tube over Each patient is unique and the airway management plan
the AEC. All patients should receive anti-emetic medication should be individualized and constructed on case-by-case
(ondansetron, 4–8 mg IV). basis. Being prepared with additional airway management
strategies during induction, maintenance and emergence
from anesthesia will improve patient safety. Adherence to
22. Review of case-series the principles of the American Society of Anesthesiologists
difficult airway algorithm should result in reduction of
Xue et al. [54] published a retrospective study of 1683 patients anesthesia-related morbidity and mortality.
with PBC neck, aged 1.5–67 years, scheduled for contracture
release under general anesthesia. Based on atlanto-occipital
extension and Mallampati class, patients were divided into Conflict of interest
two groups: group 1 – managed by use of Macintosh
laryngoscopy; group 2 – managed by use of fiberoptic stylet There are no conflicts of interest.
laryngoscope (FOSL). Number of intubation attempts, intuba-
tion time and complications are presented in Table 2. In group
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