a 4-year - old boy ( 55 months , 16.3 kg , 102 cm ) was diagnosed with chronic hypertrophic tonsillitis and adenoid vegetation due to severe stertorous breathing and sleep apnea , and he was hospitalized in the otorhinolaryngology department for tonsillectomy and adenoidectomy . . however , the patient had severe stertorous breathing and recently developed mild dry coughing two days prior to surgery . according to the preoperative interview with the guardian one day before the surgery , the patient was born via cesarean section due to breech presentation weighing at 3.5 kg and had no specific medical history . an intramuscular injection of 0.25 mg atropine was given as premedication 30 minutes prior to entering the operating room . when we approached the patient for induction of anesthesia , malformation was found on the right side of the patient 's face . when asked once again about the patient 's medical history , it was found that the patient was diagnosed with congenital auricular atresia after birth , and hearing test conducted 3 months after birth confirmed hearing loss of the right ear . later , the patient was diagnosed with goldenhar syndrome accomopanying partial loss of the right auricle , conjunctival dermoid , and oral atresia . the right side of the patient 's face was less developed compared with the left , thus making his face asymmetric . the auricle was undeveloped , with only a partial earlobe remaining in his right ear ( fig . the mallampati oral opening view was unavailable due to agitation of the patient , and the patient presented irregular dentition . the patient was sitting on the bed due to dyspnea that occurs in a lying position . while the guardian remained to help stabilize the patient , ketamine ( 2 mg / kg ) was administered to induce anesthesia . with spontaneous breathing intact , the patient was taken to the operating room . in the waiting room , pulse oxygen saturation was measured at 98% in a sitting position . however , after ketamine was given for induction of anesthesia , pulse oxygen saturation fell to 94% in the operating room with the spontaneous breathing intact . other vital signs showed blood pressure of 125/85 mmhg and heart rate of 170 beats / min . preoxygenation was performed , and 0.6 mg / kg of rocuronium and 1 g / kg of fentanyl were administered intravenously . manual ventilation was attempted using a mask , but the mask did not fit due to facial deformity . for effective manual ventilation , gauze was filled in the buccal area to achieve the best possible fit for the mask . oral airway was inserted and an open airway was maintained using both hands , and then manual ventilation was attempted with the help of an assistant . a skilled anesthesiologist used a # 2 macintosh curved laryngoscope blade to lift the epiglottis with an assistant manipulating the larynx , but failed to check the glottic opening . with a 4.5 mm cuffed tube ( mallinckrodt , covidien , ireland ) and a stylet , the authors used blind technique for intubation , but it was unsuccessful . a video laryngoscope ( glidescope & gvl 4 , verathon medical , canada ) was used in the following attempt , but even entering the glottis was difficult due to the narrow oral cavity . thus , a supraglottic airway device ( i - gel size 2 , intersurgical , lithuania ) was inserted for proper ventilation . then a bronchoscope ( lf - dp , olympus , tokyo , japan ) was inserted through i - gel for visualization of the glottic opening , a part of which was shown on the upper side of a the bronchoscopic view . by lifting the mandible and applying pressure on the cricoid cartilage , the authors moved the glottic opening to the center of the the bronchoscopic view . after deciding to attempt fiberoptic bronchoscopic intubation , a cuffed 4.5 mm tube was covered with lubricant , and fiberoptic bronchoscopic intubation was performed through a laryngeal mask airway . 2 ) . in order to remove the i - gel while maintaining the tube , first , the connecting part at the proximal end of the tube was removed . then , a tube exchanger ( airway exchanger catheter , cook , canada ) , which was thicker than the tube , was used to secure the tube in place . the authors checked the depth of the tube through a stethoscope and conducted mechanical ventilation . during the surgery , 1.5 and 2.5 vital signs were maintained , as follows : blood pressure 115 - 130/70 - 85 mmhg , heart rate 140 - 170/min , pulse oxygen saturation 98 - 100% , and capnogram 32 - 41 mmhg . after the spontaneous breathing of the patient was recovered , 0.004 mg / kg glycopyrrolate and 0.2 mg / kg pyridostigmine was injected intravenously . severe stridor and even transient apnea occurred while the patient was lying in the recovery room . when 5 l / min of oxygen was supplied by a mask , pulse oxygen saturation was up to 98% , but it fell to 84 - 88% during room air respiration . the patient did not feel much discomfort because he had long been adapted to low oxygen saturation . after being stabilized for 2 hours in the recovery room , the patient was supplied with 2 l / min of oxygen through a nasal cannula and transferred back to the patient 's room . total operative time and anesthesia time were 75 minutes and 105 minutes , respectively , and 80 ml of hartman solution was administered . on the fourth day following the surgery , the patient was discharged without any further problems . goldenhar syndrome , also known as oculoauriculovertebral dysplasia ( oavd ) , was reported by goldenhar in 1952 . it is a congenital defect characterized by preauricular appendages , blinded fistulas , epibulbar dermoid , and vertebral anomalies . in particular , difficult ventilation and airway are expected due to hemifacial microsomia , microgenia , mandibular hypoplasia , and vertebral anomalies . several cases have been reported in which difficult airway occurred or was expected in children diagnosed with goldenhar syndrome . there is a report on successful intubation in a 4.5-year - old child with goldenhar syndrome and associated mandibular hypoplasia by using a straight blade and a 4.0 mm tube after a failed attempt using a curved blade and a 4.5 mm tube . another case reported successful general anesthesia using a laryngeal mask airway ( lma ) without intubation during ophthalmic surgery in a 10-year - old goldenhar syndrome patient complicated with severe microsomia . there is also a case of successful fiberoptic bronchoscopic intubation in a 6-year - old patient with right facial deformity and occipitocervical fusion . in addition , one case reported a successful pediatric fiberoptic bronchoscopic intubation through an lma during a planned trancheostomy for respiratory failure in a 19-day - old infant ( 3.6 kg ) while the infant was awake . it was also reported , in a case in which airway obstruction occurred after extubation in a 4-month - old baby , that an open airway was maintained using an lma . airway management can be difficult during anesthesia in children with goldenhar syndrome , and various methods have been attempted . also , an lma can be used as a passage for intubation , as evidenced by johnson 's use of an lma as an method of airway management to administer anesthesia to an infant in tracheostomy . in our case , a traditional approach to intubation was attempted but did not succeed . thus , a supraglottic airway device was inserted , in line with the asa guidelines . this device enabled adequate airway management so that proper ventilation was possible without gas leakage . also , the authors succeeded in intubation by using an i - gel instead of an lma . this method has not yet been reported in pediatric patients , but several cases reported successful intubation using an i - gel on adults . emmerich and tiesmeier   reported a case in which fiberoptic bronchoscopic intubation succeeded using a 6.5 mm tube and a size 5 i - gel , after a failed fiberoptic bronchoscopic intubation , in a 69-year - old patient who was expected to have a difficult airway . .   failed in intubation in a 54-year - old patient by using a laryngoscope ; a size 4 classic lma was then inserted , but failed to achieve adequate ventilation . when a size 4 i - gel was used , adequate ventilation was achieved , and fiberoptic bronchoscopic intubation was successful using a 7.0 mm tube . sharma et al .   attempted 2 intubations through a laryngoscope in a teenage boy for general anesthesia but failed in both attempts . then he inserted a size 4 classic lma and achieved adequate ventilation but twice failed in fiberoptic bronchoscopic intubation . when he attempted fiberoptic bronchoscopic intubation by replacing the size 4 lma with a size 4 i - gel , intubation was successful . as these cases and other reports suggest , an i - gel allows stable airway management when ventilation is difficult to achieve through a mask airway or when intubation itself is difficult . in addition , an i - gel can function as a guide for a bronchoscope . an i - gel , therefore , can be used as a passage for intubation . however , lmas show some shortcomings compared with i - gel. first , lmas have limits in using cuffed tubes . according to recently published reports , lee et al .   succeeded in fiberoptic bronchoscopic intubation through an lma in two patients , ages 6 and 24 , who were expected to have difficult airways . he used a size 2.5 classic lma and uncuffed 4.5 mm tube for the 6-year - old patient and a size 3.0 lma and uncuffed 4.5 mm tube for the 24-year - old patient . likewise , intubation is possible through an lma , but uncuffed tubes were used for the ease of lma removal after intubation . also , when using size 2.5 and smaller lmas , the pilot area of cuffed tubes can not pass the lma . in our case , as a tonsillectomy was planned , a cuffed tube had to be used for intubation . we succeeded in intubation by using a cuffed tube and a size 2.0 i - gel. also , lmas such as size 2 lma classic and size 1.5 lma unique , commonly used for pediatric patients , has more dense aperture bars in the mask bowl compared with larger lmas ( fig . therefore , a size 2.0 i - gel is more useful than lmas of the same or smaller size in pediatric intraoral surgeries that require the use of cuffed tubes . however , the use of an i - gel does not address all of the problems associated with lmas . the mallinckrodt tubes ' pilot can not pass i - gels of size 1.5 and smaller , similar to size 2 and smaller lmas . therefore , if possible , it is desirable to use an uncuffed tube in infants in which a size 1.5 i - gel is used . if a surgery that requires the use of cuffed tubes is planned , it is worth considering the use of an uncuffed tube first to intubate and then replacing it later through a tube exchanger . in this case , it was not easy to remove an i - gel after intubation while maintaining the tube in place . to prevent the tube from being removed when i - gel was removed , the authors used the tube exchanger , thicker than the tube , in order to secure the tube in place . however , the pilot part of the tube overlapped with the tube exchanger and could not pass . thus , the authors pulled back the i - gel until the part of the tube was exposed in the oral cavity , secured the tube in place with forceps , and removed the i - gel completely . it was successful , but the authors slightly fell into a disorder at the time . it appears that , for this process to be safer and easier , a longer pediatric tube is necessary , and covering the whole tube with lubricant is necessary . similar to the authors ' opinion , mauch et al .   reported that the use of a smaller supraglottic airway device and uncuffed tube had advantages and expected that an extended tube would produce more desirable results . in conclusion , difficult airway management is expected in pediatric patients with facial deformity such as goldenhar syndrome . supraglottic airway devices can be useful for proper ventilation when difficulties occur in airway management after induction of anesthesia . also , the use of an i - gel for fiberoptic bronchoscopic intubation has benefits due to its structural characteristics . in particular , it is more beneficial in pediatric intraoral surgeries that require the use of cuffed tubes . however , additional research and the development of more suitable devices are necessary for broader application .
the i - gel is a single - use supraglottic airway device introduced in 2007 which features a non - inflatable cuff and allows passage of a tracheal tube owing to its large diameter and short length of the airway tube . in this case , the authors experienced a difficult airway management on a 4-year - old boy with underlying goldenhar syndrome who underwent a tonsillectomy . 
 intubation using a laryngoscope was unsuccessful at the first attempt . in the following attempt 
 , we used the i - gel supraglottic airway for ventilation and were able to achieve successful intubation with a cuffed tube by using fiberoptic bronchoscope through the i - gel supraglottic airway . 
 the authors suggest that i - gel is a useful device for ventilation and it has many advantages for tracheal intubation in pediatric patients with difficult airway .