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 Table of Contents  
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 88-91

Asleep fibreoptic bronchoscope-guided nasal intubation in a child with bilateral temporomandibular joint ankylosis

Department of Anaesthesiology, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India

Date of Submission28-Apr-2022
Date of Acceptance13-Jul-2022
Date of Web Publication16-Aug-2022

Correspondence Address:
Dr. Sumedha Mehta
Department of Anaesthesiology, Block Q, Flat No 1, Doctors Staff Quarters, Smt. Kashibai Navale Medical College and General Hospital, Narhe, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_20_22

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Pierre Robin sequence (PRS) with bilateral temporomandibular joint (TMJ) ankylosis is a rare and challenging case for anaesthesiologists. A 6-year-old girl with PRS along with bilateral progressive TMJ ankylosis was scheduled for gap arthroplasty. Her mouth opening was <1 finger. Securing the airway in a syndromic child with mandibular hypoplasia was challenging. We performed an asleep fibreoptic bronchoscope (FOB)-guided nasotracheal intubation while retaining spontaneous breathing. Managing a difficult paediatric airway needs expertise. We believe that with the use of FOB, difficult airways can be successfully and safely managed.

Keywords: Dexmedetomidine, fibreoptic bronchoscopy, paediatric airway, Pierre Robin sequence

How to cite this article:
Panse NA, Mehta S, Adate KU, Gangthade PA. Asleep fibreoptic bronchoscope-guided nasal intubation in a child with bilateral temporomandibular joint ankylosis. Airway 2022;5:88-91

How to cite this URL:
Panse NA, Mehta S, Adate KU, Gangthade PA. Asleep fibreoptic bronchoscope-guided nasal intubation in a child with bilateral temporomandibular joint ankylosis. Airway [serial online] 2022 [cited 2022 Sep 28];5:88-91. Available from: https://www.arwy.org/text.asp?2022/5/2/88/353812

  Introduction Top

Managing a difficult airway in a syndromic child is challenging for the attending anaesthesiologist, requiring detailed understanding of the congenital anomaly, planning, skills and experience. Pierre Robin sequence (PRS) comprising micrognathia, retrognathia and glossoptosis results in airway obstruction and feeding difficulties.[1]

  Case Report Top

We report a case of a 6-year-old girl weighing 15 kg with PRS along with restricted mouth opening diagnosed to have bilateral temporomandibular joint (TMJ) ankylosis. The child had progressive limitation of mouth opening since birth associated with snoring and mouth breathing. Perinatal and family history was not significant, and milestones were at par with age. Detailed preanaesthetic evaluation and airway examination revealed severe micrognathia, retrognathia and glossoptosis with irregular dentition and adenoid hypertrophy. As mouth opening was <1 finger breadth, modified Mallampati class could not be assessed [Figure 1]. Adenoid hypertrophy was being treated with a steroid spray. All investigations including electrocardiogram and chest X-ray were normal. After parental counselling and consent, the child was posted for gap arthroplasty under general anaesthesia. Our primary plan was fibreoptic-aided nasal intubation under sedation, failing which our back-up plan was a tracheostomy. The operating room was prepared with small-sized endotracheal tubes (ETTs), nasal airways, cricothyrotomy set, paediatric fibreoptic bronchoscope (FOB) (3.5 mm), drugs as per body weight and warming equipment. A paediatric surgeon was requested to standby for an emergency tracheostomy.
Figure 1: Micrognathia with irregular dentition and mouth opening of <1 finger breadth

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Electrocardiography, noninvasive blood pressure, pulse oximetry and capnography monitoring were established. After calculating the safe dose of lignocaine, airway preparation was done with 4% lignocaine nebulisation, 2% lignocaine jelly and xylometazoline 0.05% nasal drops in preparation for nasal FOB. A 3.0 mm ID ETT was negotiated through the right nostril up to the nasopharynx and connected to a Jackson-Rees circuit for oxygenation throughout the procedure. The child was premedicated with intravenous (IV) glycopyrrolate 4 μg/kg, midazolam 0.03 mg/kg, ondansetron 0.1 mg/kg, ketamine 1 mg/kg, dexmedetomidine 0.5 μg/kg and 2%–4% sevoflurane in oxygen administered through Jackson-Rees circuit, making sure that the patient kept breathing spontaneously. The FOB was preloaded with a 4.0 mm ID uncuffed ETT and introduced through the left nostril. On advancing the FOB, bleeding was encountered due to enlarged adenoids which made the advancement of FOB difficult. After continuous suctioning, FOB could be negotiated till the epiglottis. With assisted neck flexion and gentle external laryngeal manipulation, the larynx could be visualised and the FOB was negotiated up to carina with spray-as-you-go technique while visualising tracheal rings. The ETT was then railroaded over the fibrescope and after confirming the placement of the ETT by capnography, propofol 2 mg/kg, fentanyl 2 μg/kg and vecuronium 0.1 mg/kg were administered intravenously.

Once bilateral equal air entry was confirmed, the ETT was secured, an 8 FG infant feeding tube was passed through the right nostril [Figure 2] and minimal throat packing was done. Anaesthesia was maintained with sevoflurane (1%–2%) in oxygen and nitrous oxide (50:50). Intraoperative analgesia was maintained with IV paracetamol 15 mg/kg. All vital parameters including end-tidal carbon dioxide and airway pressures were monitored throughout the surgery. Blood loss was calculated and replaced accordingly. Two episodes of high peak airway pressure were noted intraoperatively due to kinking of ETT which were corrected immediately. The patient withstood the procedure well and at the end of the procedure, a check laryngoscopy was attempted with an improved mouth opening of three fingers. The larynx was very anteriorly placed and the vocal cords could not be visualised. The patient was shifted with the ETT in situ to the paediatric intensive care unit. After 24 h, the child was taken to the operation theatre for extubation. Difficult airway equipment including a videolaryngoscope (blade #2) was kept ready. The child was awake and following commands. As mouth opening was 3 fingers, a gentle laryngoscopy was performed and extubation done. She recovered well postoperatively.
Figure 2: Lateral profile view of the child after intubation

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  Discussion Top

FOB is the gold standard in managing the difficult paediatric airway.[2] The nasopharyngeal passage stabilises the FOB and improves control of the thin paediatric FOB, providing a straight-forward path to the larynx as evidenced by faster times to visualise the carina and perform successful tracheal intubation via the nasal route. The smaller diameter, greater flexibility and reduced tip angulation of the paediatric FOB make its use difficult to master.

This case presented a special challenge as TMJ ankylosis is rare in the paediatric population. In our patient, mouth opening was <1 finger. Hence, the use of a supraglottic airway or direct laryngoscopy was technically difficult. As our patient had a hypoplastic, retrognathic mandible, restricted mouth opening with glossoptosis and grade 2 adenoid hypertrophy, we decided to proceed with nasal fibreoptic intubation. A clinical indicator of the severity of ankylosis is the interincisural distance which if <5 mm is termed as 'complete ankylosis'.

In anticipation of the risk of laryngospasm, desaturation and bleeding during fibreoptic intubation, we maintained spontaneous respiration throughout the procedure. Laryngospasm is described as a primitive reflex initiated to prevent aspiration in patients under deeper planes of anaesthesia. Although laryngospasm can occur in awake patients, the incidence is low and the use of ketamine preserves the upper airway reflexes, thereby preventing laryngospasm.[3] Airway blocks were difficult to administer as patient was uncooperative with distorted anatomy. There are limited data available to the real incidence of difficult airway management in paediatric patients.[4]

MacLennan and Robertson reported a child with Treacher–Collins syndrome where intubation was performed using blind location of the glottis with a gum elastic bougie using ketamine as a sole anaesthetic agent. Ketamine facilitated spontaneous respiration for a long duration, allowing reasonable manipulation of the laryngoscope despite a small mouth, prominent upper teeth and a large tongue.[5] We also used ketamine 1 mg/kg to provide adequate sedation while maintaining spontaneous respiration. Addition of dexmedetomidine provided more complete sedation with good haemodynamic stability facilitating FOB-guided intubation.

Goswami et al. mentioned in their report that since awake fibreoptic intubation is not feasible in children, induction with an inhalational agent such as sevoflurane and maintaining spontaneous ventilation is an alternative method which we utilised.[6] Another alternative was suggested by Kundra et al. who reported the use of an adult FOB passed through one nostril and ETT through the other nostril with intubation being performed under video-camera assistance.[7]

  Conclusion Top

Paediatric FOB-guided nasotracheal intubation always remains the gold standard in managing children with difficult airways. Use of an ETT for continuous oxygenation and inhalational agent delivery helped maintain adequate depth of sedation. Preoperative evaluation and preparation by an experienced anaesthesiologist were the keys behind the successful management of this case. This technique increases the safety and precision of securing a difficult paediatric airway.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given consent for images and other clinical information to be reported in the journal. The guardian understands that the name and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.


We acknowledge and appreciate the inputs from the Department of Oromaxillofacial Surgery, Sinhgad Dental College and Hospital, Pune.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Gangopadhyay N, Mendonca DA, Woo AS. Pierre Robin sequence. Semin Plast Surg 2012;26:76-82.  Back to cited text no. 1
Sims C, von Ungern-Sternberg BS. The normal and the challenging pediatric airway. Paediatr Anaesth 2012;22:521-6.  Back to cited text no. 2
Gavel G, Walker RW. Laryngospasm in anaesthesia. Contin Educ Anaesth Crit Care Pain 2014;14:47-51.  Back to cited text no. 3
Güven O. A clinical study on temporomandibular joint ankylosis in children. J Craniofac Surg 2008;19:1263-9.  Back to cited text no. 4
MacLennan FM, Robertson GS. Ketamine for induction and intubation in Treacher-Collins syndrome. Anaesthesia 1981;36:196-8.  Back to cited text no. 5
Goswami D, Singh S, Bhutia O, Baidya D, Sawhney C. Management of young patients with temporomandibular joint ankylosis-A surgical and anesthetic challenge. Indian J Surg 2016;78:482-9.  Back to cited text no. 6
Kundra P, Vasudevan A, Ravishankar M. Video assisted fiberoptic intubation for temporomandibular ankylosis. Paediatr Anaesth 2006;16:458-61.  Back to cited text no. 7


  [Figure 1], [Figure 2]


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