Authors: Alanzi A et al.
Cureus 17(11): e95994, November 2025. DOI: 10.7759/cureus.95994
This case report describes the anesthetic management of a three-year-old girl with Dandy-Walker syndrome (DWS), severe obstructive sleep apnea (OSA), laryngomalacia, micrognathia, seizure disorder, and recurrent aspiration pneumonia undergoing supraglottoplasty and adenoidotonsillectomy. The combination of posterior fossa malformations, craniofacial anomalies, and OSA presented major anesthetic challenges.
Preoperative care included pulmonology consultation and bronchodilator therapy to optimize airway status. Induction was performed with sevoflurane while maintaining spontaneous ventilation, followed by propofol infusion and dexmedetomidine for sedation and airway stability. Airway topicalization with lidocaine minimized reflexes during bronchoscopy. Endoscopic assessment revealed type 1 and type 2 laryngomalacia, after which intubation with a cuffed 4.5-mm tube allowed surgery to proceed safely. Normocapnia (EtCO₂ 35–40 mmHg) and BIS monitoring guided anesthesia depth, preventing intracranial pressure surges and seizure risk. Due to extensive airway manipulation and severe OSA, the patient remained intubated for 24 hours and was successfully extubated in the pediatric ICU.
The discussion emphasized three major concerns: intracranial pressure control, difficult airway management, and postoperative respiratory risk. Propofol was favored for its neuroprotective and anticonvulsant properties; dexmedetomidine provided sedation while preserving ventilation. Topical and IV lidocaine reduced laryngospasm risk. OSA required avoidance of opioids and sedatives, with postoperative non-opioid analgesia and close monitoring.
The authors compared their experience with previous DWS cases, highlighting consistent challenges—micrognathia, airway obstruction, and ICP control—and reinforcing the role of multidisciplinary coordination.
What You Should Know:
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Dandy-Walker syndrome often involves difficult airway anatomy and elevated intracranial pressure, requiring individualized anesthetic planning.
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Maintenance of spontaneous ventilation during induction minimizes risk in complex pediatric airways.
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Propofol and dexmedetomidine provide complementary neuroprotective and airway-stabilizing benefits.
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Severe OSA increases postoperative respiratory risk; extended ICU observation is recommended.
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Collaboration among anesthesiology, otolaryngology, and neurology is critical for safety and outcome optimization.
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