Children with limited oral opening can be safely managed without a tracheostomy

Objective. To describe airway management of children with limited oral opening that does not allow for routine orotracheal intubation by direct laryngoscopy. To analyze the incidence and outcome of airway compromise or loss in patients without a tracheostomy in place. Study Design. Case series with chart review. Setting. Tertiary children's hospital. Subjects. Children with limited oral opening that does not allow for routine orotracheal intubation. Methods. Children treated at Children's Hospitals and Clinics of Minnesota from 1997 to 2012 with severe trismus were identified and included in the study. Hospital and clinic records were reviewed. Results. Ten children (mean age, 13 years; range, 7-17 years) were identified for inclusion into the study. A total of 109 operations requiring general anesthesia (average of 10.9 per patient; range, 0-23) were performed on patients without a tracheostomy in place. Flexible fiber-optic nasotracheal intubation was performed in 58 cases. The remainder of airway control was by mask ventilation (33 cases), various methods of orotracheal intubation (10 cases), unknown (6 cases), and laryngeal mask airway (2 cases). There was a total of 118 patient-years of follow-up without a tracheostomy tube in place (average of 11.8 years per patient). During this period, there were no episodes of acute airway compromise that resulted in neurologic deficits. Conclusion. Children with limited oral opening that does not allow for routine orotracheal intubation with direct laryngoscopy may be safely managed without a tracheostomy, even when the child requires frequent procedures under general anesthesia.