title: Difficult tracheal intubation induced by maxillary distraction devices in craniosynostosis syndromes.
abstract: BACKGROUND
  Difficult intubation occurred during anaesthesia for removal of maxillary distraction devices in five of seven children with syndromal craniosynostoses (four with Apert, two with Pfeiffer and one with Crouzon syndrome).
  
  
  METHODS
  Intubation was assessed in terms of laryngeal view and an established intubation difficulty score and had been straightforward before device insertion. Difficulty was induced by trismus due to device insertion and by increased maxillary prominence. This was compounded by preexisting mandibular hypoplasia. Cephalometric analysis, with each child acting as their own control, demonstrated anterior displacement of the maxilla and increased maxillary vertical height, as well as increased protuberance of the maxillary incisors.
  
  
  RESULTS
  All five difficult tracheal intubations were associated with preoperative Mallampati scores of 3 or 4 and the nine straightforward intubations with scores of 1 or 2. Maximal interincisor distance was less than the lower 95% confidence limit for age in all five children who were difficult to intubate at the time of device removal. No child had a failed intubation, but all had significantly increased intubation difficulty.
  
  
  CONCLUSIONS
  In view of the risks of trauma, hypoxia and aspiration associated with difficult direct laryngoscopy, we recommend elective fibreoptic intubation at anaesthesia for removal of maxillary distraction osteogenesis devices in these children.
authors.affiliation: Great Ormond Street Hospital for Children, London, UK.
authors.forename: John
authors.initials: J
authors.lastname: Roche
authors.forename: Geoff
authors.initials: G
authors.lastname: Frawley
authors.forename: Andrew
authors.initials: A
authors.lastname: Heggie
mesh_terms: D000293:Adolescent; D000768:Anesthesia, General; D002508:Cephalometry; D002648:Child; D002675:Child, Preschool; D003398:Craniosynostoses / Q000601:surgery*; D020878:Device Removal; D005336:Fiber Optic Technology / Q000295:instrumentation; D006801:Humans; D007442:Intubation, Intratracheal; D008447:Maxillofacial Prosthesis; D019857:Osteogenesis, Distraction / Q000295:instrumentation*