Management of the Difficult Airway in Children

Airway management and endotracheal intubation in children usually present no difficulties for the experienced anaesthetist. In infants, access may be slightly more problematic because of certain anatomical variations: the tongue is large relative to the mandible and the larynx is more cephalad than in the older child. In infants below the age of four months the epiglottis is at the level of the first cervical vertebra; at six months it has moved down to the level of the third cervical vertebra. Unlike the epiglottis in adults, the epiglottis in infants is hard and narrow and is folded into an inverted U shape. These features together give rise to what many people refer to as the ‘anterior larynx’, but in fact are just due to the relative macroglossia and the higher placement of the larynx. The anatomical variations between infants, children and adults should be easily overcome by use of straight-bladed laryngoscopes which can pick up the epiglottis and reveal the larynx. The children who present major difficulties for the anaesthetist are not easily missed. In this paper I focus on congenital causes. Others are retropharyngeal abscess, burns, trauma and Still's disease.