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| CASE REPORT |
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| Year : 2008 | Volume
: 52
| Issue : 3 | Page : 334-336 |
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Bonfils Retromolar Intubation Fibrescope for Difficult Intubation
Kirti N Saxena1, Richa Pangte2, Prachi Gaba3
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 Acceptance | 20-Mar-2008 |
| Date of Web Publication | 19-Mar-2010 |
Correspondence Address:
Kirti N Saxena
B-302 Gitanjali Apartments, Vikas Marg Extension, New Delhi - 110092
India
 Source of Support: None, Conflict of Interest: None  | Check |
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 |
 Introduction | |  |
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 | | |
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 | | |
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 | | |
| 1. | Bonfils P.Difficult intubation in Pierre-Robin children, a new method: the retromolar route. Anaesthetist 1983; 32: 363-367.  |
| 2. | Henderson JJ.The use of paraglossal straight blade laryngoscopy in difficult tracheal intubation. Anaesthesia 1997;52:552-60. [PUBMED] |
| 3. | Maybauer MO, Maier S, Maier S. An unexpected difficult intubation. Bonfils rigid fibrescope. Anaesthesist 2005;54:35-40. |
| 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. [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. [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. [PUBMED] |
| 7. | Rudolph C,Schlender M. Clinical experiences with fibre optic intubation with the Bonfils intubation fibrescope. Anaesthesiol Reanim 1996;21:127-30. [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. |
| 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. |
| 10. | Mason RA. Learning fibreoptic intubation : fundamental problems.Anaesthesia 1992;47:729-731. [PUBMED] |
[Figure 1], [Figure 2], [Figure 3]
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