Airway Management of a Patient With a Giant Frontoethmoidal Encephalocele: A Pediatric Case Report

Meningoencephalocele is a rare congenital midline defect of cranial bone fusion characterized by herniation of the brain and meninges through the skull. In addition to the challenges of managing a major neurosurgical procedure in a pediatric patient, airway management in this group of patients requires advanced skills, and a difficult airway should be anticipated from the start. Since awake intubation is not an option in most pediatric cases with airway anatomy abnormalities and maintaining an adequate seal with a pediatric face mask is often impossible, airway management in patients with these lesions is highly challenging. We present the case of a 12-month-old girl with a postnatal diagnosis of frontoethmoidal meningoencephalocele who underwent craniotomy, followed by encephalocele resection, subsequent frontal cranioplasty, and reconstruction of the nasal bone defect. We discuss the timely adaptation of an adult face mask (size five) rotated 180o over the patient's entire face to perform adequate preoxygenation and spontaneous ventilation assistance with hand-bag ventilation after the inhalational induction of general anesthesia. After obtaining adequate depth of anesthesia, an initial video laryngoscopy with pediatric Medan (R) was performed. The epiglottis and vocal cords were identified, and rocuronium was administered. After complete muscle relaxation, another video laryngoscopy was performed and orotracheal intubation was successful on the first attempt. As an alternative airway, we planned orotracheal intubation using a pediatric fiberoptic bronchoscope with the aid of a laryngeal mask airway if required. As a rescue measure, we also ensured that an otolaryngologist was present in the operating room if a tracheostomy was deemed necessary. We aim to raise awareness of the importance of safe practices in anesthesia, reinforce preventive measures during careful airway examination, and plan approach strategies.