a 15-year - old male , who was diagnosed with prs , was scheduled for repair of a pectus excavatum under general anesthesia .
he had a history of tracheostomy at birth , a cleft palate operation at 1 month of age , and tracheostomy closure 1.5 years later . according to the consulting otolaryngologist
, there was no pathological condition except sleep apnea . at the physical examination of his airway , the boy had the typical appearance of prs .
he also had a mouth opening limitation and the maximum distance between incisors was 2.8 cm .
his mallampati class was grade 3 , but he had no limited neck movement . because his parents disagreed with a conscious fiber - optic intubation for fear that their son would have a hard time during the procedure , we planned to induce anesthesia with propofol and succinylcholine and then intubate with the mcgrath mac video laryngoscope and a malleable stylet .
we also prepared a laryngeal mask airway ( lma ) in case of difficult mask ventilation , according to the difficult airway guidelines .
finally , if all of these methods failed , we planned to wake him because his parents wanted to cancel the surgery if the intubation failed .
anesthesia was induced in the operating room with 2 mg / kg propofol and 1 mg / kg succinylcholine after preoxygenation with 100% oxygen .
after full muscular relaxation , the mcgrath mac video laryngoscope was inserted into the oropharynx and was placed posterior to the epiglottis because the epiglottis obscured the glottis and provided a half view of the glottis ( cormack - lehane grade 2 ) . however , insertion of the 60 angled malleable styletted ett failed because the tube tip could be seen posterior to the arytenoids despite the external laryngeal maneuver .
the tube tip reached the glottis , but there was considerable resistance advancing the ett through the vocal cords even though the stylet was withdrawn .
finally , the frova intubating introducer with its tip modified as much as a 60 angle , similar to the mcgrath mac video laryngoscope , was inserted through the vocal cords ( figs . 1 and 2 ) .
the frova intubating introducer was used as a railroad for the ett , and there was no difficulty advancing the ett under vision with the video laryngoscope ( fig .
correct placement of the ett was further confirmed by auscultation and end - tidal co2 detection .
we applied the mcgrath mac video laryngoscope and frova intubating introducer for endotracheal intubation in this case of a difficult airway and showed that the strategy was effective and successful .
fiber - optic intubation is currently the gold standard for elective difficult airway management , but alternatives are described in the literature .
the intubation techniques described include : airtraq optical laryngoscopy ( prodol meditec sa , vizcaya , spain ) , video laryngoscopy , non - fiber - optic intubation via lma , fiber - optic intubation via lma , and a paraglossal approach with tube advancement over a gum - elastic bougie .
we chose a mcgrath mac video laryngoscope and malleable stylet because the mcgrath mac video laryngoscope provides a good view of the glottis , and a malleable stylet helps direct the ett to the glottis .
as a precaution for a failed intubation , we also prepared a frova intubating introducer and fiber - optic bronchoscope for combined use , and an lma in case of a difficult mask ventilation according to the difficult airway guidelines .
it is important to have backup airway management plans because it takes less than 10 min for patients with a difficult airway to become hypoxic . at our first attempt ,
insertion of the 60 angled malleable styletted ett failed because the tube tip could be seen posterior to the arytenoids .
external laryngeal pressure and withdrawal of the blade to lessen tilting of the laryngeal axis and to reduce the introducing angle may have been helpful . however , these maneuvers did not work in our case .
the tube tip reached the glottis , but there was considerable resistance advancing the ett through the vocal cords .
this occurs from time to time , as the tube tip may strike the anterior tracheal wall because of the angle of the stylet . in this case
, the operator withdraws the stylet approximately 4 cm , withdraws the video laryngoscope by 1 - 2 cm and rotates the ett slightly to facilitate passage into the trachea .
we withdrew the stylet and rotated the ett to pass it into the trachea but failed .
finally , the frova intubating introducer with its tip modified as much as a 60 angle like the mcgrath mac video laryngoscope was attempted , and it was inserted through the vocal cords with no difficulty .
this was a remarkable result because the tip of the 60 angled malleable styletted ett , which had the same curvature as the frova intubating introducer , could be seen posterior to the arytenoids even though the external laryngeal maneuver was applied .
unlike the macintosh laryngoscope , video laryngoscopes require a tilting force rather than a lifting force , and this force makes mouth opening too small to handle the ett . because the frova intubating introducer has a smaller outer diameter than that of an ett ( 4.6 mm for the frova intubating introducer vs. 8.9 mm for a # 6.5 ett ) , it is easy to handle in a narrow space , as shown in this case .
thus , the frova intubating introducer with its tip modified as much as 60 reached the glottis , whereas the same 60 angled malleable styletted ett could not .
although the frova intubating introducer was designed for use with a macintosh laryngoscope in the line of sight , and its tip should not be modified during macintosh laryngoscopy , modifying its tip and combined use with a video laryngoscope provides some advantages .
first , the frova intubating introducer allows for easy handling in the narrow space under a video laryngoscope .
second , it creates less trauma than a styletted ett . less resistance advancing the 60 angled frova intubating introducer through the vocal cords than that of a 90 angled malleable
finally , preparing the frova intubating introducer is less time consuming than a fiber - optic bronchoscope , so it can be used for an unanticipated difficult intubation .
the use of a video laryngoscope combined with a fiber - optic bronchoscope has been reported previously .
fiber - optic bronchoscopy is a method of inserting an ett with a video laryngoscope .
however , this technique has some disadvantages ; it needs more than two experienced anesthesiologists and one anesthesiologist should be familiar with the fiber - optic bronchoscope .
in addition , the maintenance and preparation of a fiber - optic bronchoscope are time - consuming , limiting its use in the case of an unanticipated difficult intubation .
use of a lma is another good option in patients with prs ; however , we thought it would be dangerous in this case because lung compliance might have decreased during repair of the pectus excavatum .
we did not know that tracheal intubation with a macintosh laryngoscope would be a success or failure in this patient because we did not use a macintosh laryngoscope initially .
sometimes tracheal intubation is attempted with a macintosh laryngoscope in anticipated difficult airway with little possibility of success , even though other methods for intubation , such as a video laryngoscope or fiber - optic bronchoscope , are available .
the difficult airway management guidelines developed by the difficult airway society of the uk suggest that the initial tracheal intubation plan should not include more than four attempts .
the fact that multiple attempts can lead to tissue trauma causes more difficult intubation in subsequent trials , makes mask ventilation difficult , and results in hypoxia .
therefore , it is important to choose the first intubation plan carefully because fewer attempts lead to less airway trauma and increased patient safety . in conclusion , we propose that the combined use of a mcgrath mac video laryngoscope and a frova intubating introducer is a useful option for a difficult airway with an upper airway anomaly .
 patients with pierre robin syndrome are characterized by micrognathia , retrognathia , glossoptosis , and respiratory obstruction and are prone to have a difficult - to - intubate airway . 
 the mcgrath mac video laryngoscope provides a better view of the glottis than a macintosh laryngoscope , but it is not easy to insert an endotracheal tube through the vocal cords because a video laryngoscope has a much greater curvature than that of a conventional direct laryngoscope and an endotracheal tube has a different curvature . the frova intubating introducer is used as a railroad for an endotracheal tube in cases of a difficult airway . 
 we thought that a combination of these two devices would make it easy to insert an endotracheal tube through the vocal cords , as a mcgrath mac video laryngoscope provides a better glottic view and the frova intubating introducer is a useful device for placing an endotracheal tube through the glottis . 
 we report a successful endotracheal intubation with use of the mcgrath mac video laryngoscope and frova intubating introducer in a patient with pierre robin syndrome . 
Case Report
Discussion