Journal of Anaesthesiology Clinical Pharmacology

: 2011  |  Volume : 27  |  Issue : 4  |  Page : 575-

Intubating children with giant occipital encephalocele in lateral position: Right or left side?

Charu Mahajan, Girija Prasad Rath 
 Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Girija Prasad Rath
Department of Neuroanaesthesiology, Neurosciences Center, 6th Floor/Room No. 9, All India Institute of Medical ­Sciences, New Delhi - 110 029

How to cite this article:
Mahajan C, Rath GP. Intubating children with giant occipital encephalocele in lateral position: Right or left side?.J Anaesthesiol Clin Pharmacol 2011;27:575-575

How to cite this URL:
Mahajan C, Rath GP. Intubating children with giant occipital encephalocele in lateral position: Right or left side?. J Anaesthesiol Clin Pharmacol [serial online] 2011 [cited 2021 Apr 17 ];27:575-575
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We read with interest few recent articles on anesthetic management of children with giant occipital encephalocele. [1],[2] We routinely manage such cases in our institute, [3] and often encounter difficulties in securing the airway. Various modalities have been suggested to overcome difficulties during laryngoscopy and tracheal intubation. The commonly practiced methods include positioning the child laterally, supporting the swelling with a doughnut, or placing the child's head beyond the edge of the table with an assistant supporting the head.

We would like to suggest few points on airway maneuvering in lateral position. Placing the child in right lateral position makes laryngoscopy easier for a right-handed person who uses the left hand to hold the laryngoscope, and vice versa for a left-handed person. Therefore, the side of lateral positioning needs to be decided much before the attempt of intubation. Otherwise, a relatively easy intubation may get complicated by restriction of anesthesiologist's hand movements. Needle decompression of encephalocele sac, under sterile precaution, has been proposed as an alternative approach to overcome difficulties of intubation. [2] However, the resultant rapid decompression of ventricular system may lead to fatal complications such as cardiac arrest owing to traction of cerebral neuronal pathways involving brainstem nuclei. [4]

An advantage of lateral position is that it obviates the risk of raised intracranial pressure that may occur with compression of encephalocele sac during laryngoscopy in supine position. Inhalational induction of anesthesia should be preferred over intravenous technique, especially when a difficult airway is anticipated. Neuromuscular blockade should be avoided until the airway is secured. Anesthetic challenge in children with encephalocele is not just restricted to airway management, proper positioning, maintenance of temperature, and replacement of blood loss also require vigilance.


1Arora S, Bharti N, Bala I. Sudden cardiac arrest during repair of giant occipital encephalocele with microcephaly. J Anaesthesiol Clin Pharmacol 2010;26:259-60.
2Goel V, Dogra N, Khandelwal M, Chaudhri RS. Management of neonatal giant occipital encephalocele: Anaesthetic challenge. Indian J Anaesth 2010;54:477-8.
3Mahajan C, Rath GP, Dash HH, Bithal PK. Perioperative management of children with encephalocele: An institutional experience. J Neurosurg Anesthesiol 2011 May 31. [Epub ahead of print] PMID:21633311.
4Mahajan C, Rath GP. Is intraoperative cardiac arrest enough for cancellation of surgery in patients with neural tube defect? J Neurosurg Anesthesiol 2010;23:59-60.