When Normal Looks Deceptive: Unexpected Difficult Airway in a Child with Subtle Craniofacial Anomalies

Abstract

Airway management in pediatric patients with craniofacial anomalies can be unpredictable, particularly when syndromic features are subtle or masked. We report the case of a 2-year-old boy (20 kg) posted for orchidopexy, whose preoperative airway assessment was limited by irritability, and whose dysmorphic features resembled those of his parents, masking suspicion of an underlying syndrome. Induction was carried out uneventfully, but intubation attempts with 4.5 mm and bougie-guided 4.0 mm endotracheal tubes failed. Placement of an i-gel size 2 initially secured ventilation, though progressive hypercarbia ensued, with end-tidal carbon dioxide (EtCO₂) rising to 75 mmHg. Video laryngoscopy subsequently revealed a markedly anterior larynx, severe supraglottic edema, and a ranula-like swelling. Administration of hydrocortisone and dexamethasone was followed by successful intubation with a bougie-guided 3.5 mm tube, after which ventilation normalized, and the remainder of anesthesia was uneventful. This case highlights the importance of anticipating hidden syndromic airway challenges, recognizing the limitations of supraglottic devices in the setting of edema, and relying on early video laryngoscopy, smaller tube selection, corticosteroids, and advanced adjuncts to ensure safe outcomes.