Dynamic Airway Management in a Child With Extensive Laryngotracheobronchial Papillomatosis

Extensive juvenile-onset recurrent respiratory papillomatosis (JORRP) can turn the paediatric airway into a constantly changing operative field, particularly when disease extends from the larynx into the tracheobronchial tree.Shared airway surgery, the risk of obstruction and the dynamic changes that occur during lesion excision make anaesthetic management especially challenging.We describe the anaesthetic management of a two-year-old child with extensive laryngotracheobronchial papillomatosis and a long-term tracheostomy after failed decannulation.A staged airway strategy was used, with spontaneous ventilation preserved throughout.At induction, the existing metallic tracheostomy tube was exchanged for a cuffed flexometallic endotracheal tube.After lesion debulking, a significant air leak developed, so the tube was changed to a microlaryngeal surgery (MLS) tube to improve the tracheal seal while maintaining surgical access.For excision of distal airway lesions, the MLS tube was removed, and tubeless oxygenation was provided with transnasal humidified rapid-insufflation ventilatory exchange (THRIVE).The procedure was completed successfully, and the tracheostomy tube was reinserted at the end.Intraoperative challenges included airway sharing, significant airway leak, and laryngospasm, all of which were managed successfully.Successful management requires anticipation of dynamic airway changes and the ability to transition between different ventilation strategies.