Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Rigid Fiber-Optic Device Intubation in a Child With Temporomandibular Joint Ankylosis Bibiana Vitkovic, MD,  Morena Milic, MD PhD, y Dorotea Filipan, MD, z and Emil Dediol, MD, PhD §jj Abstract: The authors present a case of rigid fiber-optic device intubation in an 8-year-old boy with posttraumatic temporoman- dibular joint ankylosis. For this intention, a 5 mm diameter Bonfils fiberscope was used. Such practice has never been described before in pediatric patients with temporomandibular joint ankylosis. The procedure was successful and without complications. Therefore, the authors conclude that this method represents a useful alternative in difficult airway management in children with limited mouth opening. Key Words: Airway management, bonfils, fiberscope, pediatric, temporomandibular joint ankylosis T emporomandibular joint (TMJ) ankylosis is a fibrous-osseous fusion of the condyle of the mandible to the glenoid fossa of the temporal bone. It may be caused by congenital malformation, infection, arthritis or previous TMJ surgeries, but the main cause in childhood is trauma. 1 As such, a pediatric patient with severely limited mouth opening presents a challenge for the anesthesiolo- gists. Anticipated difficulty in the airway management requires expertise and dependable intubation techniques. 2 Multiple methods are described in the literature. 1–3 However, rigid fiber-optic device has never been reported in pediatric population with TMJ ankylosis. The authors report the case of Bonfils fiberscope (BF) intubation in an 8-year-old boy with TMJ ankylosis. CLINICAL REPORT A 6-year-old boy was injured in a road traffic collision and suffered multiple fractures of the mandible (body and bilateral condyles). Initially, he underwent surgery of the mandibular body fracture, but condyle fractures were managed conservatively with intermaxillary fixation for three weeks in another hospital. In the 2 following years, and especially with the start of permanent dentition eruption, the patient has developed gradual reduction of mouth opening. On presentation, physical examination revealed maximum mouth opening of 5 mm inter-incisal distance (Fig. 1C), with 10 mm gap in the right retromolar space. Protrusion and lateral mandibular movements were impossible. Computed tomography showed bony ankylosis of the left TMJ (Fig. 1A-B). The treatment option for TMJ ankylosis in this case was surgical only. 4 Therefore, condylectomy of the left TMJ, as well as interpositional gap arthroplasty by temporalis fascia flap was indicated. 5 For this procedure, general anesthesia was required. Preoperative evaluation determined an otherwise healthy 8-year-old boy, weighing 31 kg, classified ASA I, with no history of previous anesthesia complications. It was not possible to evaluate the Mallampati score as the palate was hardly visible, thus difficult airway was anticipated. Premedication was achieved 30 minutes before surgery by midazolam 0.1 mg/kg and atropine 0.02 mg/kg intramuscular. Anesthesia was induced by slow intravenous administration of 80 mg of propofol. While maintaining mask oxygenation, muscle relaxant rocuronium 0.3 mg/kg was given intravenously. After- wards, the Heister mouth opener device was introduced on the left side, and Macintosh laryngoscope blade on the right side of the oral opening. Since only the oropharynx was visible, rigid intubation endoscope - Bonfils fiberscope (Karl Storz Endoscopy, Tuttlingen, Germany) was inserted in the right retromolar space. We assessed the view of laryngeal inlet as Cormack and Lehane grade I. Thereafter, an endotracheal tube number 5 was railroaded into the trachea, and its position was confirmed by auscultation and capnography. The operation, as planned, consisted of left condylectomy and resection of ankylotic mass through preauricular approach, fol- lowed by interpositional tissue transfer of temporal fascia flap into the created gap, in order to prevent postoperative reankylosis. During the operation, the patient was stable. Surgical procedure achieved maximum mouth opening of 25 mm inter-incisal distance, ensuing the release of ankylosis. After surgery, the child was decurarized and extubated without complications. Postoperative period was uneventful and the boy was discharged from the hospital 6 days later. In the follow-up period of 1 year postoperatively, the patient showed greatly increased mandibular mobility and mouth opening (Fig. 1D), along with successful recovery of functions. DISCUSSION Ankylosis of the TMJ in children often starts insidiously after trauma to the mandibular condyle. 1 In this condition, airway management presents a challenge for the anesthesiologists. Stan- dard technique for difficult intubation in adults is flexible fiberoptic bronchoscope (FOB) intubation. 3 However, in children with limited mouth opening, this option is not always available in every institu- tion. In a review of anesthetic techniques in pediatric patients with TMJ ankylosis, Vas and Sawant 1 described several intubating methods while also stating both their advantages and disadvantages. Among the techniques presented were blind nasal intubation and its modification semiblind intubation, then intubation over a wire passed retrograde from the trachea, as well as fiberoptic laryngos- copy and tracheostomy. Although the authors acknowledged that fiberoptic laryngoscopy would be the ideal alternative for difficult airway management, they admitted the difficulties, in terms of high price and the need for a variety of small sizes for pediatric population. Another paper presented a successful tracheal intuba- tion in a child with 12 mm mouth opening. 2 This case report argued that fiberscope-assisted videolaryngoscope technique could provide improved visualization of intubation field and therefore decrease the odds of damaging soft tissue structures. However, Bonfils device intubation was not mentioned in either of the 2 aforementioned publications. On the other hand, an article by Thong et al 6 detailed characteristics, indications, benefits, and complications of the From the  Department of Anesthesiology, Reanimatology and Intensive care Medicine, Children’s hospital; y Department of Anesthesiology, Reanimatology and Intensive care Medicine, University Hospital Dubrava; z Sestre milosrdnice University Hospital Center; § Department of Maxillofacial Surgery, University Hospital Dubrava; and jj Zagreb School of Medicine, University of Zagreb, Zagreb, Croatia. Received September 8, 2019. Accepted for publication October 8, 2019. Address correspondence and reprint requests to Emil Dediol, MD, PhD, Department of Maxillofacial Surgery, University Hospital Dubrava, University of Zagreb, Avenija Gojka S ˇ us ˇ ka 6, 10000 Zagreb, Croatia; E-mail: emildediol@yahoo.com The authors certify that they have obtained all appropriate patient consent forms. The authors report no conflicts of interest. Copyright # 2019 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000006139 BRIEF CLINICAL STUDIES The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2019 1