Enliven: Journal of Anesthesiology and Critical Care Medicine

According to the Italian Society of Anesthesiology (SIAARTI) guidelines, an awake fiberoptic intubation is the gold standard to manage a predicted difficult airway. At our institution, we are experienced in the use of the Bonfils Fiberscope® (Karl Storz), a rigid fiber optic metallic stylet, to intubate patients with expected difficult airways as well as patients with unexpected difficult airways after failed direct laryngoscopic intubation. We performed an awake retromolar fiber optic intubation in a 42-yr-old man with a temporo-mandibular anchilosis, with a very low mouth opening, with a Mallampati class 4 and an interincisor distance of 1,2 cm. A conscious sedation was performed by the administration of i.v. midazolam 0.03 mg/kg and fentanyl 2 mcg/kg. The topical anesthesia consisted in the administration of lidocaine spray 10% puffs in the oral cavity, in particular in the right vestibule with the adjunct of an instillation of lidocaine 1 % on the glottis aditus through an atomizer (Optispray®) under endoscopic vision. The retromolar approach is the method of choice in patients with limited mouth opening compared to the paraglossic technique; since the device is introduced laterally in the vestibule of the oral cavity, it can be well tolerated by the patient.