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Table of Contents
Year : 2020  |  Volume : 36  |  Issue : 1  |  Page : 131-133

Airway management using a non-coaxial fibreoptic bronchoscope guided endotracheal intubation in a case of near complete palatoglossal synechiae

Department of Anesthesiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Date of Submission10-Aug-2018
Date of Acceptance20-Mar-2019
Date of Web Publication18-Feb-2020

Correspondence Address:
Dr. Anuj Jain
B118 New Minal Residency, JK Road, Bhopal, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joacp.JOACP_250_18

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How to cite this article:
Waindeskar V, Jain A. Airway management using a non-coaxial fibreoptic bronchoscope guided endotracheal intubation in a case of near complete palatoglossal synechiae. J Anaesthesiol Clin Pharmacol 2020;36:131-3

How to cite this URL:
Waindeskar V, Jain A. Airway management using a non-coaxial fibreoptic bronchoscope guided endotracheal intubation in a case of near complete palatoglossal synechiae. J Anaesthesiol Clin Pharmacol [serial online] 2020 [cited 2021 Feb 25];36:131-3. Available from:


Present case is of an infant aged 3.5 months with Pallatoglossal band (PGB), weighing 2.6 kgs, and having severe malnutrition. Oral examination revealed PGB involving posterior part of the tongue and hard palate with only a small opening of less than 1 cm through which the oral cavity and oropharynx were communicating [Figure 1]. Direct laryngoscopy and intubation were not possible, bag mask ventilation (BMV) was also anticipated to be difficult. The plan was to perform tracheal intubation with a tracheal tube of 3 mm diameter passed pernasally under visual guidance of FOB that had already been passed through the other nostril. A cuffed endotracheal tube was considered appropriate (there was a chance of airway bleed and inability to do throat pack mandated a cuffed tube). A backup plan for emergency tracheostomy and cricothyroidotomy was kept ready alongside.
Figure 1: Pre-surgery oral cavity showing complete palatoglossal fusion with practically no communication between oral cavity and oropharynx

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Preparation included high-risk consent of perioperative asphyxia, 6 and 2 hours fasting for milk and water, respectively; premedication with injection atropine 0.02 mg/kg intramuscular 1 hour before induction; lignocaine 4% nebulization for 5 minutes; oxymetazoline nasal drops 15 minutes before nasal intubation; venous access. The patient was monitored using ECG, pulse oximeter, NIBP. Preoxygenation was done with 100 percent oxygen for 3 minutes. Anesthesia induction was done with Sevoflurane by the graduated increments method.

After ensuring BMV, fentanyl (2 mcg/kg) and succinylcholine (1 mg/kg) were given intravenously. We passed a pediatric FOB (2.8 mm bronchoscope, Olympus medical corp, Japan) through the right nostril and stationed it just above the glottis; through the other nostril we passed a 3 mm cuffed ETT and directed it towards the glottis under an indirect vision obtained from the FOB. External manipulations of ETT and larynx helped in achieving endotracheal intubation. PGBs which were mostly fibrotic were excised successfully [Figure 2] followed by tracheal extubation.
Figure 2: Post-surgery oral cavity showing excision of palatoglossal band and adequate hemostasias

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Extent of synechiae helps in deciding surgical and anesthesia plan. Excision of incomplete intramural synechiae can be done under local anesthesia or general anesthesia with BMV.[1],[2] In cases of incomplete synechiae, a paraglossal approach of intubation can be adopted using a miller blade or a Bullard laryngoscope.[3]

In a case with near complete PGB, definitive airway is necessary; hence, FOB-assisted co-axial nasal intubation (ETT rail-roaded over the FOB) in a spontaneously breathing patient seems to be the most appropriate approach. Endotracheal tubes—less than 3.5 mm diameter—cannot be railloaded on the commonly available pediatric bronchoscope (2.8 mm diameter). Most of the centers do not have flexible bronchoscopes smaller than 2.8 mm as was the case with us, so we improvised the tracheal intubation using a FOB-assisted non-coaxial approach and overcame the limitation of a coaxial technique of FOB assisted intubation.

A preoperative tracheostomy is another valid option,[4],[5] but pediatric tracheostomies have their challenges and complications, such as infection, airway bleeding, difficulties of decannulation, subglottic stenosis that enhance the morbidity, especially in pediatric patients.[6]

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Conflicts of interest

There are no conflicts of interest.

  References Top

Gharavifard M, Kashani I, Joudi M, Sharifian M, Sayedi SJ, Mohammadipanah B, et al. Surgery and anesthesia management for intraoral synechia: A case report. Iran J Otorhinolaryngol 2018;30:117-9.  Back to cited text no. 1
Cerrati EW, Ahmed OH, Rickert SM. Isolated congenital maxillomandibular synechiae. Am J Otolaryngol 2015;36:707-9.  Back to cited text no. 2
Henderson JJ. The use of paraglossal straight blade laryngoscopy in difficult tracheal intubation. Anaesthesia 1997;52:552-60.  Back to cited text no. 3
Solanki S, Babu MN, Gowrishankar, Ramesh S. Palatoglossal fusion with cleft palate and hypoplasia of cerebellar vermis. Indian J Plast Surg 2016;49:106-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
Sybil D, Sagtani A. Cleft palate lateral synechia syndrome. Natl J Maxillofac Surg 2013;4:87-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
Carr MM, Poje CP, Kingston L, Kielma D, Heard C. Complications in pediatric tracheostomies. Laryngoscope 2001;111:1925-8.  Back to cited text no. 6


  [Figure 1], [Figure 2]


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