Indian Journal of Anaesthesia  
About us | Editorial board | Search | Ahead of print | Current Issue | Past Issues | Instructions
Home | Login  | Users Online: 1416  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size    




 
CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 3  |  Page : 334-336 Table of Contents     

Bonfils Retromolar Intubation Fibrescope for Difficult Intubation


1 Professor, Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi-110002, India
2 Senior Resident, Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi-110002, India
3 Specialist, Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi-110002, India

Date of Acceptance20-Mar-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Kirti N Saxena
B-302 Gitanjali Apartments, Vikas Marg Extension, New Delhi - 110092
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions
 

The Bonfils retromolar fibrescope is a rigid fibrescope with an angled end. A 35-years- male with restricted mouth opening was scheduled to undergo reconstruction of fractured zygoma. We decided to try oral intubation under local anaesthesia with the Bonfils intubation fibrescope with a size 8.0 endotracheal tube loaded over it. This assembly was introduced from the right corner of the mouth till the curved tip had entered well inside the mouth. The scope was then brought to the midline and introduced further inside. Intubation was achieved easily.

Keywords: Retromolar approach , Bonfils fibrescope, Difficult intubation


How to cite this article:
Saxena KN, Pangte R, Gaba P. Bonfils Retromolar Intubation Fibrescope for Difficult Intubation. Indian J Anaesth 2008;52:334-6

How to cite this URL:
Saxena KN, Pangte R, Gaba P. Bonfils Retromolar Intubation Fibrescope for Difficult Intubation. Indian J Anaesth [serial online] 2008 [cited 2019 Jul 16];52:334-6. Available from: http://www.ijaweb.org/text.asp?2008/52/3/334/60646


   Introduction Top


The Bonfils retromolar fibrescope is a rigid fibrescope with an angled end [Figure 1]. It is meant for orotracheal intubation and is introduced into the oral cavity either in the midline or from the angle of the mouth similar to the technique described for molar approach for intubation [1],[2] . The endotracheal tube is loaded and fixed over the scope. It has been used in a large num­ber of patients with difficult airways [3],[4],[5],[6] , but adequate mouth opening has been considered a prerequisite for it's use [7] . However, we have used it successfully in this patient who had an interincisor gap of only 1.5cm..


   Case Report Top


A 35 years old male was scheduled to undergo reconstruction of fractured zygoma as elective surgery [Figure 2].On preoperative evaluation , he was found to be a healthy , young male with no associated disease. Airway evaluation revealed restricted mouth opening with interincisor gap of 1.5 centimetres [Figure 3] which was attributed to the fractured zygoma as the mouth opening had been adequate before the fracture accord­ing to the patient. Airway was classified as Mallampatti IV [8] with normal neck movement . The left nostril was obstructed due to the fractured zygoma . The nasal septum was deviated to the right side but the right nos­tril was patent.

The surgeon did not want nasal intubation as it was likely to interfere with the surgical procedure. In the operation theatre he was prepared for awake oral fibreoptic intubation with 2% lidocaine viscous gargles and 10% spray after giving glycopyrrolate(0.2 mg), midazolam(1 mg) and fentanyl(100mcg). The flexible fibreoptic bronchoscope was not available in the op­eration theatre so we decided to try oral intubation with the Bonfils retromolar intubation fibrescope(5mm di­ameter) with an armoured tube size 8.0 loaded over it. The first attempt was made by introducing the fibrescope from the midline, however we were unable to negotiate the angle of the scope between the inci­sors. This assembly was then introduced from the right corner of the mouth till the curved tip had entered well inside the mouth. However it could not be manipulated further. The scope was then brought to the midline and introduced further inside. With a slight upward lifting maneuver the laryngeal inlet was seen.This was sprayed with 2% lidocaine solution through the suction/injec­tion port of the fibrescope which was then guided gen­tly into the inlet . It was not possible to insert the tip beyond the vocal cords. Asking the patient to take deep breaths the tube was guided slowly into the larynx and the scope withdrawn. Intubation was confirmed by the capnograhic waveform and the patient underwent the rest of the anaesthetic procedure uneventfully.


   Discussion Top


Patients with reduced interincisor gap such as those with temporomandibular joint ankylosis are best man­aged with awake fibreoptic nasotracheal intubation. However, if nasal intubation is not desirable as was the case in our patient, then oral intubation in such patients may be difficult . The main problem in such cases is that the patient may bite the flexible fibrescope which is normally prevented by passing the fibrescope through a biteblock or airway [9] , which was not possible in our patient due to the restricted mouth opening. Secondly, the cuff can get caught between the incisor teeth and rupture during negotiation of the endotracheal tube over the fibrescope( personal observation). Since Bonfils ret­romolar fibrescope is a rigid equipment, a biteblock is not needed. By using the Bonfils retromolar fibrescope introduced by the retromolar route , we were able to circumvent both these problems. Sufficient mouth open­ing has been recommended as a prerequisite for intu­bating patients with difficult airways [7] using the Bonfils retromolar fibrescope . To the best of our knowledge this is the only case report of successful intubation with this device in a patient with such markedly reduced mouth opening. Also, the method used for intubation i,e. introducing the fibrescope by a paraglossal ap­proach [2] and then bringing it to the midline is an innova­tion done by us and is not reported in the literature. We think that as with the flexible fibrescope, the Bonfils rigid fibrescope is also better negotiated in the awake patient [10] .

 
   References Top

1.Bonfils P.Difficult intubation in Pierre-Robin children, a new method: the retromolar route. Anaesthetist 1983; 32: 363-367.  Back to cited text no. 1      
2.Henderson JJ.The use of paraglossal straight blade laryn­goscopy in difficult tracheal intubation. Anaesthesia 1997;52:552-60.  Back to cited text no. 2  [PUBMED]    
3.Maybauer MO, Maier S, Maier S. An unexpected diffi­cult intubation. Bonfils rigid fibrescope. Anaesthesist 2005;54:35-40.  Back to cited text no. 3      
4.Bein B, Worthmann F,Scholz J, et al. Comparison of the intubating laryngeal mask airway and the Bonfils intuba­tion fibrescope in patients with predicted difficult air­ways. Anaesthesia 2004;59:668-74.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Byhahn C, Meininger D, Walcher F, Hofstetter C,Zwissler B. Prehospital emergency endotracheal intubation using the Bonfils intubation fibrescope. Eur J Emerg Med 2007;14:43-6.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Maeyama A, Kodaka M,Koyama K,Okuyama S,Maruo T,Miyao H. Newly developed Bonfils retromolar intuba­tion fibrescope for difficult airway. Masui. 2006;55:494-8.  Back to cited text no. 6  [PUBMED]    
7.Rudolph C,Schlender M. Clinical experiences with fibre optic intubation with the Bonfils intubation fibrescope. Anaesthesiol Reanim 1996;21:127-30.  Back to cited text no. 7  [PUBMED]    
8.Mallampatti SR, Gatt SP,Gugino LD, et al. A clinical sign to predict difficult tracheal intubation:a prospective study.Canadian Anaesthetists Society Journal 1985;32:429.  Back to cited text no. 8      
9.Pollard BJ, Norton ML.Principles of airway management. In:Wylie and Churchill- Davidson's A practice of anes­thesia.2003 .Published by Arnold, 7th edition: 443-464.  Back to cited text no. 9      
10.Mason RA. Learning fibreoptic intubation : fundamental problems.Anaesthesia 1992;47:729-731.  Back to cited text no. 10  [PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
    Introduction
    Case Report
    Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed1851    
    Printed91    
    Emailed0    
    PDF Downloaded264    
    Comments [Add]    

Recommend this journal