A 2-yr-old patient with Pierre Robin Sequence and Ullrich congenital muscular dystrophy presented for excision of multiple maxillary and mandibular eruption cysts (image A).

Eruption cysts are dome-shaped benign lesions overlying the alveolar mucosa of an erupting tooth. Although most eruption cysts resolve without intervention, surgical intervention may be required for those that are painful, infected, or bleeding.1  Preoperative computed tomography imaging (images B and C) confirmed the presence of teeth within cystic structures, micrognathia, glossoptosis, cervical spine anomalies, and patency of the nasopharyngeal airway.

Several techniques have been described in managing the anticipated difficult pediatric airway.2,3 Awake intubation techniques in young children are challenging because of limited cooperation. General anesthesia or sedation with maintenance of spontaneous ventilation during airway instrumentation is a practical management option. The flexible fiberoptic bronchoscope can be useful for nasal intubation in children with limited mouth opening, oral pathology, or unstable cervical spine.2  A nasopharyngeal airway placed in the opposite nares can serve as a conduit to introduce volatile anesthetic and oxygen into the posterior pharynx in the spontaneously breathing patient2 ; it can also be an adjunct to improve airway obstruction and fiberoptic visualization before airway securement. Opioid analgesia should be carefully titrated in patients with preoperative airway obstruction to avoid postoperative respiratory complications.3  After excision of the maxillary and mandibular eruption cysts in this patient, 10 deciduous teeth were exposed (image D). The patient was extubated awake after placement of a nasopharyngeal airway and taken to the postanesthesia care unit without complications.

The authors declare no competing interests.

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