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Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 96-97

C-MAC videolaryngoscope: A simple solution for a difficult problem

Department of Anesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India

Date of Submission19-Apr-2020
Date of Acceptance14-Jul-2020
Date of Web Publication30-Aug-2020

Correspondence Address:
Dr. Garima Choudhary
PG Hostel, AIIMS Campus, AIIMS, Jodhpur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ARWY.ARWY_14_20

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How to cite this article:
Mital T, Choudhary G, Syal R, Kumar R. C-MAC videolaryngoscope: A simple solution for a difficult problem. Airway 2020;3:96-7

How to cite this URL:
Mital T, Choudhary G, Syal R, Kumar R. C-MAC videolaryngoscope: A simple solution for a difficult problem. Airway [serial online] 2020 [cited 2021 May 8];3:96-7. Available from: https://www.arwy.org/text.asp?2020/3/2/96/293958

Klippel–Feil syndrome (KFS) is a rare congenital condition caused by failure in the segmentation process of the cervical vertebrae during intrauterine life, resulting in fusion of the cervical vertebrae.[1] The classic triad of clinical presentation in KFS is a short neck, restricted neck movements and a low posterior hairline. It is an autosomal dominant disorder with an incidence of 1:42,000.[2] Awake fibreoptic intubation has always been the standard practice in an anticipated difficult airway, but this could pose practical difficulty in children. We describe the role of the C-MAC videolaryngoscope as an alternative to awake fibreoptic bronchoscopy for orotracheal intubation in a paediatric patient with KFS with limited neck movement (including head extension).

A 12-year-old girl, weighing 32 kg, diagnosed to have KFS Type II, was posted for occiput-C2 decompression, reduction and fixation under general anaesthesia [Figure 1]. Airway examination revealed a difficult airway with short webbed neck, reduced thyromental distance (3 cm), reduced mouth opening (1.8 cm), modified Mallampati Grade 3 and limited neck movement. She had thoracolumbar kyphoscoliosis, and radiography revealed fusion of the atlantoaxial joint [Figure 2]. Systemic examination was unremarkable.
Figure 1: Photograph of the patient showing cervical stabilisation using Philadelphia collar

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Figure 2: Fusion of C1–C2 vertebrae and D1–D2 vertebrae seen with platybasia

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In the operation theatre, the following monitoring was established – electrocardiogram, noninvasive blood pressure, pulse oximeter and temperature. In view of cervical spine instability in a paediatric patient, manual-in-line-stabilisation and C-MAC videolaryngoscope-assisted intubation was planned. A fibreoptic bronchoscope (5 mm OD) with an endoscopic mask was available as a standby in case intubation with videolaryngoscope was not possible. A skilled ear, nose and throat surgeon was also requested to standby for performing tracheostomy without extension of neck. After premedication with midazolam 0.5 mg, fentanyl 2 μg/kg and adequate preoxygenation, the patient was induced with sevoflurane and after checking the ability to mask ventilate, muscle relaxation was induced with 0.6 mg/kg rocuronium. After ensuring adequate depth of anaesthesia, laryngoscopy was performed with the adult D-blade of C-MAC videolaryngoscope with manual-in-line-stabilisation. Cormack–Lehane grade was found to be 3a, and the airway was secured with a 6.0 mm ID cuffed endotracheal tube with the help of a stylet. Anaesthesia was maintained with isoflurane in air and oxygen. Surgery was performed in the prone position and lasted for 6 h. The intraoperative course remained uneventful, and the patient was shifted to the intensive care unit (ICU) with the endotracheal tube in situ. The child was extubated uneventfully the next morning in the ICU.

Anaesthetic management of KFS is challenging due to difficulty in airway management. The main concern in these patients is a potential unstable cervical spine and abnormal atlanto-occipital junction, which make them prone to an increased risk of spinal cord injury and neurological damage, especially during laryngoscopy, intubation and positioning for surgery.[3] Although awake fibreoptic intubation is considered the best option in anticipated difficult intubation, especially with reduced mouth opening,[4] this was not feasible in our patient due to poor patient cooperation. In addition, cervical spine immobility can be better achieved during intubation using the C-MAC videolaryngoscope. Hence, we planned to do a careful C-MAC-guided laryngoscopy with manual-in-line-stabilisation. This technique has the added advantage of providing a view of the glottis without the need for alignment of the oral, pharyngeal and laryngeal axes. The field of vision of the C-MAC D-blade which is around 80° improved glottic visualisation, which was of immense help in the successful management of our case. In older children with normal mouth opening, videolaryngoscopy and flexible bronchoscopy have similar success rates.[5] In addition, the airway algorithm of the Italian Airway Society suggests the use of a videolaryngoscope as an alternative to flexible fibreoptic scope in predicted difficult airway with adequate mouth opening.[6]

Our experience suggests that the C-MAC videolaryngoscope has a definite role in the management of difficult airway in a paediatric patient and may be considered as an option in situ ations where awake fibreoptic intubation is not feasible.

Declaration of patient consent

The authors certify that they have obtained the appropriate patient consent form. In the form, the parents of the child have given their consent for their daughter's images and clinical information to be reported in the journal. The parents understand that their daughter's name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kaplan KM, Spivak JM, Bendo JA. Embryology of the spine and associated congenital abnormalities. Spine J 2005;5:564-76.  Back to cited text no. 1
Ahuja V, Kazal S, Gombar S, Thapa D, Bahadur R. Glidescope® for predicted difficult airway in Klippel-Feil syndrome. J Anaesthesiol Clin Pharmacol 2012;28:532-4.  Back to cited text no. 2
[PUBMED]  [Full text]  
Whittle IR, Besser M. Congenital neural abnormalities presenting with mirror movements in a patient with Klippel-Feil syndrome: Case report. J Neurosurg 1983;59:891-4.  Back to cited text no. 3
Daum RE, Jones DJ. Fibreoptic intubation in Klippel-Feil syndrome. Anaesthesia 1988;43:18-21.  Back to cited text no. 4
Fiadjoe J, Nishisaki A. Normal and difficult airways in children: “What's New” – Current evidence. Pediatr Anesth 2020;30:257-63.  Back to cited text no. 5
Frova G. Do videolaryngoscopes have a new role in the SIAARTI difficult airway management algorithm. Minerva Anestesiol 2010;76:637-40.  Back to cited text no. 6


  [Figure 1], [Figure 2]


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