globally , an anticipated difficult airway is managed most often with flexible fiberoptic bronchoscope ( ffb)-guided tracheal intubation . in patients with restricted mouth opening , intubation is done through the nasal route , which is unpredictable in terms of the maximum tube size allowable . during ffb - guided intubation ,
if the preloaded tube is not able to negotiate the nose , most often , the scope is withdrawn to reload a smaller tube , and the procedure is reattempted . in certain situations
we present the anesthetic management of five such cases , where we avoided redoing the procedure by using a j - tipped guide wire .
we present the anesthetic management of five cases with temporomandibular joint ( tmj ) ankylosis posted for corrective surgery , who presented to our institute over a period of 6 months .
all the patients were men in the age group of 1827 years . among the patients
all patients had varying degrees of retrognathia , and the maximum thyromental distance recorded was three finger - breadth .
nasal patency was judged by keeping a wisp of cotton in front of each nostril , and the nostril with a better air - flow was chosen for intubation .
all the patients were asked to fast for 6 h before surgery , and a written , informed consent was taken for awake intubation in view of the difficult airway . in the operation theatre ,
standard monitors were applied , intravenous ( iv ) line was established , and premedication , consisting of metoclopramide 0.2 mg / kg , glycopyrrolate 5 mcg / kg , and midazolam 10 mcg / kg , was given iv .
local anesthesia of the airway was established with a combination of 10% lidocaine spray , nebulization with 4% lidocaine , and superior laryngeal nerve blocks .
a difficult airway cart , and equipment and personnel for rapidly establishing a surgical airway were also kept ready .
all patients were provided conscious sedation with up to 70% nitrous oxide in oxygen , delivered via a nasopharyngeal airway connected to the anesthesia circuit . a jet ventilator , with its dedicated oxygen source ,
was kept ready to be connected to the working channel of the ffb and provide 100% oxygen , if required . a 7.5-mm internal diameter ( i d ) flexometallic endotracheal tube ( ett ; lma fastrach ett )
the ett was loaded onto the ffb , and after the successful negotiation of the ffb into the trachea , it was negotiated via the nostril , through the larynx and into the trachea , and finally positioned in front of the carina . in all patients ,
on attempting to rail - road the ett over the ffb , it was realized that , despite adequate lubrication , the ett could not negotiate the nasal structures .
concerned with the difficulty expected in a repeat attempt at bronchoscopy , a 1-mm - thick , 145-cm - long , metallic j - tipped guide wire was threaded through the working channel of the ffb till the carina [ figure 1 ] , and the ffb was then withdrawn , keeping the guide wire in place .
a 6.5-mm i d ett was then threaded over the guide wire and negotiated successfully through the nasal passage and other airway structures .
after the confirmation of the intratracheal tube position with exhaled carbon dioxide , the ett was fastened , guide wire removed , and induction of anesthesia done .
the ffb was used again for visualizing the carina to ensure the precarinal tube position .
the patients were monitored for 5 days after the surgery for any airway - related complications and discharged thereafter .
ffb - guided nasal intubation under local anesthesia , with the patient breathing spontaneously , is the most commonly performed procedure for airway management in patients with difficult airway , especially those with restricted mouth opening . in the nasal cavity ,
the widest space for tube passage is along the inferior meatus but this is sometimes encroached upon by a hypertrophied turbinate or deviated nasal septum . during winter months
this prevents the passage of a nasal tube , which is otherwise appropriate for age . in case the nasal passage is found to be narrow during fiberoptic - guided intubation , the whole assembly has to be withdrawn to reload a smaller ett .
this is undesirable as even minimal trauma during the first intubation attempt causes mucosal bleeding when the mucosa is edematous .
we used a 145-cm - long , 1-mm - thick , metallic j - tipped guide wire to assist in rail - roading of the ett after being positioned in the trachea via the working channel of the ffb .
the length is crucial and has to be at least 30 cm more than the length of the ffb ( suction port to tip ) to prevent the misplacement of the guide wire [ figure 2 ] .
the ffb with the j - tipped guide wire going down its working channel guide wires have played a variety of roles for assisting in tracheal intubation .
they have also been inserted in an anterograde fashion through laryngeal mask airways for subsequent endotracheal intubation , and also through ett for changing from oral to nasal route , and for changing the type of ett .
rodriguez et al . used a guide wire via the working channel of the ffb for rail - roading of the ett in a case of treacher 
have reported two cases with a difficult airway , where they left a guide wire in the trachea for assisting in rapid reintubation in the immediate postoperative period , if required . in all our cases , because of the limited mouth opening , the use of supraglottic devices was ruled out .
we chose guide wire - aided intubation ahead of blind or light - guided nasal intubation , as we had experience of this technique in patients with a normal airway .
if we had failed , we could have gone back to the original plan of attempting an ffb - guided intubation , or could have rapidly established a surgical airway .
we feel that the uniquely beveled tip of the lma fastrach ett has a lesser tendency to impinge on the turbinates or the arytenoids , and hence requires adjusting maneuvers less often , apart from causing less trauma . an airway exchange catheter can also be used to reinforce the guide wire before rail - roading the tube to minimize displacement .
 flexible fiberoptic bronchoscope - guided awake intubation is the most trusted technique for managing an anticipated difficult airway . even after successfully negotiating the bronchoscope into the trachea 
 , the possibility remains that the preloaded tracheal tube might prove to be inappropriately large , and may not negotiate the nasal structures . 
 in such a situation , the most obvious solution is to take out the bronchoscope , replace the tracheal tube with a smaller one , and repeat the procedure . 
 unfortunately , sometimes the second attempt is not as easy as the first , as minor trauma during the earlier attempt causes tissue edema and bleeding , which makes the subsequent bronchoscopic view hazy and difficult . 
 we present the anesthetic management of five cases with temporomandibular joint ankylosis where , after successful , though slightly traumatic , bronchoscope insertion into the trachea , the tube could not be threaded in . 
 we avoided a repeat bronchoscopy by making an innovative change in the plan . 
Introduction
Case Report
Discussion