Deceptively Challenging Airway Management in a CHARGE Syndrome Patient Despite Careful Preoperative Anticipation: A Case Report.

Difficult intubation is a critical challenge in anesthesia, often linked to anatomical abnormalities. CHARGE syndrome patients are known for airway difficulties due to craniofacial anomalies, yet some cases may present without obvious anatomical predictors. We report the case of an 8-year-old girl with CHARGE syndrome undergoing surgery for choanal atresia. Despite a history of multiple previous surgeries without reported intubation difficulties, she experienced difficult intubation despite the absence of classical anatomical predictors. Standard direct laryngoscopy attempts failed two times, necessitating the use of video laryngoscopy for successful intubation. Preoperative imaging revealed nasal obstruction and severe septal deviation but no significant craniofacial abnormalities that could predict intubation difficulty. This case highlights the unpredictable nature of difficult intubation in CHARGE syndrome, even in patients without apparent anatomical risk factors. The underlying cause remained unclear, suggesting the possibility of subtle airway anomalies or dynamic factors during intubation. The successful use of video laryngoscopy underscores its value in managing difficult airways in such cases. Clinicians should maintain a high index of suspicion for difficult airway management in CHARGE syndrome patients, even in the absence of overt anatomical abnormalities. Preoperative planning should include preparation for advanced airway techniques such as video laryngoscopy to improve patient safety and outcomes.