SummaryWe report a case of upper airway obstruction as a result of delayed massive lingual swelling following routine cleft palate repair in an otherwise healthy 12-month-old girl. We believe that ischaemia and venous congestion were the causes of macroglossia, after prolonged use of the Digman Dott tongue retractor. In any dificult and lengthy repair, we recommend the prophylactic insertion of a nasopharyngeal airway under direct vision by the surgeons after surgery to prevent potential upper airway obstruction. Key wordsAnaesthesia; paediatric. Complication; macroglossia. Airway; obstruction. Surgery; cleft palate.Palatoplasty is a relatively common procedure and the overall incidence of postoperative morbidity varies from 15 to 26% [I, 21. Haemorrhage and airway obstruction are the most frequent major complications [2]. Upper airway obstruction after cleft palate repair is most commonly associated with laryngospasm, but it is also a well recognised complication in patients with pre-existing craniofacial anomalies such as Pierre-Robin syndrome [3] and following primary pharyngeal flap reconstruction [4, 51. Life-threatening airway obstruction as a result of lingual swelling is unusual. Re-establishment of an adequate airway can be extremely difficult, if not impossible. In this report, we describe a case of massive lingual swelling shortly after routine palatoplasty in an otherwise normal child and we review the potential risk factors, pathogenesis, clinical course, preventive measures and the management of this complication. Case historyA 12-month-old, 8.6 kg girl presented for elective cleft palate repair. She had been delivered vaginally at term following an uncomplicated pregnancy. Her birth weight was 2.58 kg and she had a complete bilateral cleft palate. Apart from recurrent middle ear infections and delayed phonologic development, her perinatal history was uneventful. Pre-operatively, physical examination revealed a healthy girl with a central, wide soft palate cleft, but an otherwise normal airway. She was given premedication of trimeprazine 24 mg orally, 30 min before surgery.Following inhalational induction with isoflurane in oxygen and nitrous oxide, an intravenous infusion of 0.18% saline in 4.3% dextrose was started at 40ml.h-'. After administration of atracurium 5 mg and fentanyl 10 pg intravenously, the trachea was intubated easily with a 4.0-mm uncuffed oral-RAE tube (Mallinckrodt Lab. Ltd. Athlone, Ireland).The child was placed in the Trendelenberg position, with the neck hyperextended. A Digman Dott self retaining tongue retractor was inserted to optimise surgical exposure. The cleft edge was infiltrated with lignocaine 0.5% 5ml with 1 : 200 000 adrenaline. A V-Y pushback palatoplasty was performed. The operation was technically difficult because of the large cleft and relatively small mouth. The entire procedure lasted 3 h and 45 min, with the tongue retractor in place during most of the operation. Total blood loss was approximately 60 ml and was replaced with 70 ml of stable plasma protein ...

Objective To report the clinical experience in using the Airtraq® in awake tracheal intubation in patients with known or potential difficult airway, or unstable cervical spine. Methods Case series study. Twenty patients with known or potential difficult airway, or unstable cervical spine who underwent elective operations and might require awake fibreoptic intubation were recruited. After standardised topical anaesthesia of the airway, awake intubation was performed using the Airtraq®. The duration of the intubation procedure, the intubation difficulty scale (IDS), the rate of successful placement of endotracheal tube and patient's satisfaction were recorded. Results Fifteen out of the twenty patients were successfully intubated with the Airtraq® under awake condition leading to an overall success rate of 75%. Eleven of them were intubated in the first attempt. The mean duration of intubation was 1 min 33 s. Concerning the degree of difficulty of intubation using the Airtraq®, as evaluated with the IDS, 20% was ranked as easy and 80% was slightly difficult. Excessive secretion, patient gagging, inability to cooperate and inadequate view of larynx were the major reasons of failed intubation. Eighty percent of the patients considered the intubating procedure with the Airtraq® under awake condition acceptable. In general, patients felt mild pain and discomfort and were satisfied with the intubation process. Conclusion Airtraq® may be a useful alternative of flexible bronchoscope for awake intubation with low rate of minor complications in the elective operation setting. (Hong Kong j.emerg.med. 2015;22:248-255)