When performing tracheal intubation with an Airway Scope® (AWS) (Pentax, Tokyo, Japan), an introducer blade or Intlock (ITL) must be installed in the AWS. Until now, however, only an adult ITL has been available, which should not be used during paediatric difficult intubation. We report a case of Cornelia de Lange syndrome, in which the trachea was intubated using a paediatric ITL installed in an AWS.

A 7-year-old boy, 8.4 kg and 50 cm, was scheduled to undergo bilateral orchidopexy for bilateral cryptorchidism. Anaesthesia was slowly induced by sevoflurane inhalation. After intravenous administration of rocuronium, intubation was attempted, but the epiglottis was not visible under direct laryngoscopy due to limited neck extension. Intubation was then attempted using an AWS equipped with a paediatric ITL. The glottis was seen, the target mark on the AWS monitor screen was aligned with the tracheal opening, and a 4-mm tracheal tube was inserted, after small adjustments in the positioning of the AWS. The tube was removed uneventfully after successful surgery.

The paediatric ITL entered the Japanese market in February 2012, but no clinical reports have yet described the use of the device in children with intubation difficulties. In patients with Cornelia de Lange syndrome, tracheal intubation can be difficult [1-4], and fibreoptic intubation is commonly performed [2-4]. However, gaining a view of the tracheal opening when advancing the tip of the fibrescope through the small gap between the epiglottis and the posterior wall of the larynx can be difficult. In this instance, raising or inverting the epiglottis using the AWS tip might be expected to furnish a better view of the tracheal opening.

Small adjustments were needed because the paediatric tracheal tube was soft, had a narrow internal diameter, and tended to deviate from the correct path between the tip of the ITL and the glottis due to the effect of gravity, a problem that might be resolved by use of a preloaded stylet within the tracheal tube, or by inserting the tracheal tube through the mouth without an ITL, guiding the tube to the glottis under monitored vision.

Two types of paediatric ITLs are now available, for neonates and for infants (Fig. 1). The neonatal ITL was used in this case. In paediatric cases, since significant individual differences in body shape exist due to associated malformations and developmental disorders, selecting an appropriately sized ITL before inducing anaesthesia is often difficult, so both types of paediatric ITL should always be prepared in advance.


Figure 1. Configuration of each introducer blade or Intlock (ITL). ITL-N, the Intlock for neonates; ITL-P, the Intlock for infants (paediatrics); ITL-S, the standard Intlock for adults.

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  2. References
  • 1
    August DA, Sorhabi S. Is a difficult airway predictable in Cornelia de Lange syndrome?. Pediatric Anesthesia 2009; 19: 7079.
  • 2
    Guzman J. Use of a short flexible fiberoptic endoscope for difficult intubations. Anesthesiology 1997; 87: 15634.
  • 3
    Tsukazaki Y, Tachibana C, Satoh K, Fukada T, Ohe Y. A patient with Cornelia de Lange syndrome with difficulty in orotracheal intubation. Japanese Journal of Anesthesiology 1996; 45: 9913.
  • 4
    Hirai T, Nitahara K, Higa K, Iwakiri S, Shono S, Katori K. Anesthetic management of an infant with Cornelia de Lange syndrome. Japanese Journal of Anesthesiology 2006; 55: 4546.