Podcast Transcript: Evaluation & Management of an Infant with a Small Jaw

[Dr. Gopi Shah]
Let's talk about, so now you have a baby scheduled for the OR. This is where I feel like whether you're doing the distraction or not, as an otolaryngologist, especially pediatrics, you're going to be part of that airway intubation, DLB, ours are always DLB distraction.

Usually, nobody's done-- Most of the time, not usually. Most of the time the baby's never been intubated. We don't know what's going to happen at induction. We know that, eventually, most distraction surgeons want a nasal intubation, I would say most of the time.

We do want to try to look at the rest of the airway before the distraction to check for subglottic stenosis, tracheomalacia, any other secondary lesions. It's very important to have your airway plan before the baby's in the room.

What's your airway plan? What instruments do you like? What's your conversation with your team, your OR team, anesthesia? How does that-- I feel like that's where, as an otolaryngologist, that's a baby we could lose. That's a baby where the airway can go bad, but that's our job there. Tell me what the airway plan is for you.

[Dr. Brianne Roby]
Yes. I would also say, and the first distraction case each fellow does with me, I say, you always assume that this kid is going to have a nightmare airway. It doesn't matter if on the spectrum of severity of Robin sequence, they don't look as bad. You really don't know how they're going to act until they've gotten some anesthesia. The first thing I will say is that this is not a case where you want an anesthesia resident, a first year anesthesia resident to be doing the anesthesia. This is where you want an experienced anesthesiologist, so probably not even one that just started. You want someone who you've worked enough with that you feel comfortable together managing airway stuff.

I've talked to the head of anesthesias before and been like, "I need you to be in this case and not the other person. Not because I don't love the other person, but they're new and I haven't done a bad airway with them yet. They can be in there, but I need you to be in there." I can't emphasize that part enough. Number two, this is not a case where you say, "Well, we'll let anesthesia give it a try. If it doesn't go well, then we'll take over." I think as an otolaryngologist, you should be ready to be in control of the airway from start to finish. Going there, I will say stepwise with our fellows.

Step one, normal, just using a normal laryngoscope, whether it's the Miller-- I always do a straight one, be either a Miller laryngoscope or a Parsons. I do like the Parsons, not for any other DL bronch, except for with kids that have a cleft because the Parsons is a little bit wider. With the tongue and the glossoptosis, I feel like you have a little bit better control with a wider laryngoscope. This is like the one time where I actually will use the Parsons. It's basically, you do the DL.

What do see with that, and a little bit of cricoid pressure, you have a view. I'll have the fellow take the telescope and quick just show me the rest of the anatomy and show me that everything else is normal. Now, for what it's worth, I get really annoyed when people say that babies with glossoptosis also have laryngomalacia. If you want to say that the definition of laryngomalacia is a floppy epiglottis, well, there's no way to have glossoptosis and not have a floppy epiglottis.

After the distraction, if they still have a floppy epiglottis, you can tell me that there's laryngomalacia. At the time of the DL bronch, you can't say that because it's more likely the glossoptosis causing the retroflex epiglottis. Anyway, that's an annoying end on my part because you'll look at data, and it's like, "All these babies had laryngomalacia." Maybe.

If with a normal DL and cricoid pressure, they can get the view, fantastic, great. Do the telescope, do the exam, put the breathing tube in and we'll just put it through the nose and do a nasal trachea intubation. Sometimes if the kid is not doing great, they're starting to desat and we have a great view, I actually will just orally intubate the kid. For me, the nasal tube is nice, but it's not necessary during surgery. If I feel the need to just get the oral tube in, I just do. If that goes great, great.

My next step is I always have the GlideScope set up for these kids, always. The reason why, it's amazing how often that you don't have a good view with just a normal laryngoscope, but you get the GlideScope in there and you can see how anterior it is and all of a sudden you have a really good view. There've been a number of these kids that I've intubated just with the GlideScope.

The reason that matters to me is when you take these babies up to the NICU and you're like, "If this baby suddenly extubates--" By the way, they are easy to intubate with the GlideScope. It is our job to be educating anyone else who might have to deal with this baby's airway. If you can just use the GlideScope, and many of the ICU settings now have them, it's just get the GlideScope, it should be an easy intubation with that. I do always have the GlideScope and I like that a lot.

If that doesn't work, but I can see the arytenoids with a DL, a lot of times these kids I've intubated over a telescope. I always have a telescope loaded with an endotracheal tube ready to go because I honestly think out of all things as an otolaryngologist that will help you get the airway, it's that. If you can do a DL and you can see the arytenoids and get your telescope up the anterior, you can slide in over the telescope and that's a great skill to have. It's what sets you apart, again, from anesthesia and things like that, is the ability to know how to use a telescope and intubate over a telescope.

Last but not least is the flexible fiber optic intubation nasally. This is from my standpoint in a perfect setting. I like this, again, because it's the easiest way to do a nasal intubation. I also think if you are comfortable with a flexible nasal intubation for these kids that maybe even as you get older, I'll give you an example. Last night I got called for an OAV kid who can't open her mouth even two millimeters because she's got such bad trismus and anesthesia couldn't intubate, but I can go do the flexible intubation.

That's, again, that's what sets you apart from an airway standpoint. That's my final step. Last but not least, I always have a trach set in the room ready to go. I don't think you can underestimate having that available. You hope you never have to use it because you hope that with different techniques and maneuvers you're going to be fine without it. That's my stepwise ladder.

Now along those things is talking with your anesthesiologist. I've had a number of kids where the minute we didn't attempt to do the DL and we didn't have a view, immediately turning the baby onto their side and mask ventilating on the side or even prone, bagging them up and then putting them back supine, because a lot of them are going to be a really hard mask. I always have a towel clip on the field and I hate grabbing the tongue, but I've certainly done it before.

These are just little tricks, have everything ready. The one thing I have, I really have emphasized with my fellows is, there are some cases where you give people lots of attempts and you're not worried and they're an easy mask and they're an easy ventilation, and so you keep trying the same thing a few times before you move on. Most of these kids, if I trust my fellows technique or my own technique and I take a look and I can't even remotely get what I need, I don't say, "Okay, well, let me try that again." It's next up the ladder because the longer you spend on these kids, the more likely they are to either have a spontaneous laryngospasm or something, and or because bleeding or something like that.

These are the kids that you don't mess around with multiple attempts. In communicating with anesthesiologists, I flat out say, "Here's my ladder approach. Here's what I'm going to try," so that they know what's going through my mind. We try to keep them spontaneously breathing because they're always going to be able to support themselves better than me, but they always have a paralytic on the field ready to go just in case there's a laryngospasm. Those are the things that, again, you've got communicate it with your anesthesiologist ahead of time.

[Dr. Gopi Shah]
I, in my mind, have a very similar ladder, like what if they're maskable, what are we using to mask to the DL. I like a number one Phillips, which I know every time I might ask for one, especially in a preemie or a infant, a newborn, they're like, "That's so big." Like you said, with the Parsons, it's the same thing. It's never too big. It gets the tongue out the way. That's something that Romaine Johnson is like always get-- I always just use the number one Phillips based on what I learned with him.

Let me ask you a question. Do you ever go out of order in the sense of do you ever just start with the flex through the nose, because you're going to have to intubate or we prefer that. Try to intubate, secure the tube with your flex, maybe, but also been able to look at the airway, and then do a DL, or do you feel like you don't have a good assessment of the airway to then pass on because you have a nasal intubation that's precessing your DL?

[Dr. Brianne Roby]
Yes. The answer to your question is yes, I have gone straight to a flexible fiber optic nasal intubation, but then I do not think doing a DL afterwards is realistic. Do you have something to guide your way? You have something holding the tongue forward. Your brain automatically knows, if I just follow this nasal tracheal tube, I'm going to get to where I'm supposed to be going. I have done it, but then I don't pass off to my NICU that, hey, this is going to be an easy intubation, because if I have a nasal tracheal tube in and then I do a DL with a Phillips laryngoscope and it's like, I'm like, "Oh, this was easy. It's a grade one view."

It's probably not an easy grade one view and my mind is automatically playing just distortion tricks on me. That's the only difference. I don't think it's wrong. I think there are plenty of people who go straight to a flexible intubation and that's their airway assessment. They're looking for laryngomalacia, whether or not they believe that can happen when you have glossoptosis, but they're looking for subglottic stenosis. Without doing true measurements, can you say-- You would notice if there was a super congenital stenosis or looking for tracheomalacia.

They're looking for all those things with a flexible scope and you can certainly do it. I think in terms of me, to me, the bigger purpose of doing like a DL bronch at the beginning is less so looking for secondary lesions, honestly, and more so that I can hand off to teams who might be taking care of this child that this airway is really bad, or this airway is actually not too bad and an experienced anesthesiologist would be able to intubate this child without any help type situation.

[Dr. Gopi Shah]
Now let's say the airway is secured and you're getting set up for your distraction. Do you monitor marge on these babies?

[Dr. Brianne Roby]
I do. Honestly, it always goes off the entire time. To me, you still have to be safe looking for the marge and it's not like other cases where you rely on it to identify it. For me, it's that constant reminder that the anatomy is really tiny and that you just need to be safe in your anatomy. To me, it's just more of that reminder not to take it for granted that the marge is there.

To do the dissection, I automatically find, and it's a little bit challenging in newborns because their submandibular glands are like the size of a pinky nail, but my goal automatically is to go straight, subplatysmal and find that submandibular gland and then go straight up to the mandible, and so then you know that you'd be keeping it safe, but I do monitor it. I think you could easily do this procedure and not monitor it. For me, it's just that reminder.

[Dr. Gopi Shah]
Yes. There's internal fixation and external. Can you tell us the differences in those?

[Dr. Brianne Roby]
Yes. The internal distractors mean that the plates and the screws and the most importantly, the part of the device that's going to distract, so spread apart when you do the distraction is all under the skin. In those cases, the only thing that sticks out from the skin is where the actual distraction arm is. Most of us put it under the mastoid tip. Some people will actually have it come out anteriorly underneath in the front part of the neck, but most of us go posteriorly.

That's the only part of the device that shows. As opposed to external devices, which has the pins that go through the mandible, but the rest of the distraction arm sticks out as an external fixation device from it. They look like they've got this massive hardware on their inferior border of their mandible for the time that it's there. The benefit to the external devices, you can get it so that it distracts in multiple directions, as opposed to the internal devices, which generally only distract in one direction.

Now for straightforward Robin sequence kids, they usually only need distraction in one direction, and that's just in the anterior posterior direction. I, 95 out of 100 times will do an internal device especially for Robin sequence kids, primarily because nursing care is easier. Nurses aren't so freaked out by it. Parents aren't so nervous about it. I think in the end, the scarring that's from it is much better. The internal devices, the only scar is you have a small incision just in their neck, but you can make that look pretty subtle, and then just the pin site underneath their ear.

For the external devices, you still have to have the neck incision, but you've got these pins that go in essentially on the face near the inferior border of the mandible. When all is said and done, they've got these scars on their actual face. They're small, they're little pin sites, but you can see them. I don't like that scar as much, but primarily I don't like the external device because I just think the nurses get really nervous about caring for it, and parents get nervous about how it looks when the kids go home.

The external device I've used a couple of times for kids that, again, syndromic that maybe their mandible was so asymmetric from one side to the other that I was going to have to distract in multiple directions. That's almost always for the older kids. That's really not likely for a newborn. That would be in the Treacher Collins asymmetry or hemifacial microsomia where you're really having to distract different amounts for different directions. Those are the ones where I'm more likely to use the external devices.

[Dr. Gopi Shah]
I see. The one thing I know not to circle back in terms of pre-op assessment, does your CT help you decide what directions and vectors and all that stuff? Is that where the CT is helpful? Do you routinely get CTs?

[Dr. Brianne Roby]
I don't always get CT scans. CT scans are helpful for two reasons. They're helpful in kids who are syndromic, who might have same asymmetry. For instance, I had a child recently that had OAV and has pretty hypoplastic condyles. Figuring out if they're even a distraction candidate for the syndromic kids, I think is really helpful. The other place I like it is if I do want to use 3D imaging, like pre-surgical planning.

Some people like to use that for all of it, and some people don't use it much at all. I tend to use it for kids where if I'm not going to be distracting them for a couple of weeks, because they need to grow, they need to feed, they need to declare themselves, a CT scan in those settings, and then getting the 3D imaging is helpful. Primarily it helps, honestly, for a routine Robin kid, it helps show the tooth roots, and so you can plan out ahead of time.

The inferior alveolar nerve, you can mark out ahead of time where you're going to put your pins in, your screws in, and then how you're going to make your osteotomy, and which area you can mark out where to be careful for the inferior alveolar nerve. Without the 3D imaging, honestly, it doesn't otherwise change my technique much. We still always find inferior alveolar nerve. We are looking for tooth roots, we're using the shorter screws that would be less likely to because damage.

I do use it, but I don't necessarily think you need it for non-syndromic kids. Again, there are some people who use it for all of it, and that's not wrong either. What I tend to find is that there'll be a newborn with Robin sequence, and we've been watching, trying to decide if they need it. About the time we decide that they need it, parents are like, "Okay, cool, so can we have surgery tomorrow?" You're like, "Well, it's like a three hour long surgery, maybe not tomorrow." To do the imaging, the 3D imaging and pre-planning, they can rush it in about a week, but it's definitely a delay. If I don't think it's going to change how I do the procedure or my technique, I don't necessarily use it.