Airway Management in Children with Noma Sequelae Undergoing Craniomaxillofacial Reconstructive Surgery

Background: Noma (cancrum oris) is an exclusive disease of childhood characterized by ulcerative necrosis of the maxillofacial structures, affecting up to 1,40,000 children annually. It is fatal in 80 to 90% of cases in the acute setting. Survivors are left with disfiguring maxillofacial deformations that make airway manipulation for reconstructive surgery very challenging.

Materials and Methods: Sixteen patients with chronic sequelae of noma, underwent maxillofacial reconstructive surgery at the Noma Hospital for Children, Sokoto, Nigeria. The procedures were done by Medicines Sans Frontiers (OCA) mission. The Each patient posed significant airway challenges due to anatomic malformations, trismus, and restricted neck movements. Lack of preoperative imaging and limited resources added to the challenge. We were able to surmount these with the use of a three-tier hierarchical plan: plan A (intended airway management strategy), plan B (secondary management strategy), and plan C (surgical access to the trachea).

Results: Preoperative workup included measuring thyromental, sternomental, and inters incisor distances, neck movements, and mouth opening. Of the 16 patients in this series, 14 were intubated using plan A. Two required deployment of plan B and none required plan C. We predominantly used fiber optic and nasal intubation for these patients.

Conclusions: Maxillofacial reconstructive surgery for Noma poses a huge challenge to the anesthesiologists, especially in children. Adequate planning, screening, and assessment of the airway with primary, secondary, and back-up plans are crucial. With this strategy in place “cannot intubate, cannot ventilate” situations can be handled during an emergency. Psychological and nutritional rehabilitation is essential prior to surgery.

Publication History

Article published online:
25 March 2020