Restricted mouth opening is a challenging airway in pediatric patients with temperomandibular joint (TMJ) ankylosis. The fiber-optic bronchoscopic nasotracheal intubation technique continues to be the gold standard for difficult airway, among the techniques available such as submandibular intubation, retrograde intubation, and tracheostomy. However, awake fiber-optic bronchoscopy (FOB) is difficult to achieve in pediatric patients. Prior planning of the anesthetic method and effective collaboration with the surgeon are crucial for excellent outcomes in such challenging airway cases. We present a successful awake fiber-optic bronchoscopy with high-flow nasal oxygen (HFNO), airway blocks, and deep sedation in the case of bilateral TMJ ankylosis of a pediatric age group with reduced mouth opening. We conclude that awake intubation using HFNO and airway blocks helps to achieve oxygenation and ease of intubation in difficult airway management.

Temporomandibular joint (TMJ) ankylosis is generally characterised by a complex aetiology, with several contributing causes, including infections, autoimmune diseases, trauma, and congenital anomalies. This case report describes a three-year-old female suffering from traumatic temporomandibular ankylosis with retrognathia, severe mouth-opening restriction, and obstructive sleep apnea (OSA). The present case highlights the difficulties with TMJ ankylosis, especially when access to healthcare is sought out late and delayed diagnosis is prevalent. Mandibular distraction osteogenesis and awake fiberoptic intubation were used in the surgical and anaesthetic management of this case, with the otorhinolaryngology team on standby to perform a tracheostomy if required, highlighting the necessity of a multidisciplinary approach in such cases. Patients with TMJ ankylosis have significant life-altering changes, including psychological stress, chewing difficulty, speech difficulties, facial distortion, and speech impediment. When OSA progresses, it also presents more health risks. For the purpose of treating TMJ ankylosis, avoiding serious problems, and enhancing patient well-being, prompt diagnosis and therapy are crucial. In order to optimise patient results, this case study highlights the need for knowledge and research in the treatment of TMJ ankylosis as well as the requirement of medical professionals working together in a synergistic way.

BACKGROUND: We investigated how syndromic versus nonsyndromic forms of micrognathia impacted difficult intubation outcomes in children. Primary outcome was the first-attempt success rate of tracheal intubation, secondary outcomes were number of intubation attempts and complications. We hypothesized that syndromic micrognathia would be associated with lower first-attempt success rate.
METHODS: In micrognathic patients enrolled in the Pediatric Difficult Intubation Registry (08/2012-03/2019) we retrospectively compared demographic and clinical characteristics between children with nonsyndromic and syndromic micrognathia using standardized mean differences (SMD) and assessed the association of the presence of syndrome with the primary and secondary outcomes using propensity score matching analysis with and without matching for airway assessment findings.
RESULTS: Nonsyndromic patients (628) were less likely to have additional airway abnormalities. Syndromic patients (216) were less likely to have unanticipated difficult intubation (2% vs. 20%, SMD 0.59). First-attempt success rates of intubation were: 38% in the syndromic versus 34% in the nonsyndromic group (odds ratio [OR] 1.18; 95% confidence intervals [95% CI] 0.74, 1.89; p = .478), and 37% versus 37% (OR 0.99; 95% CI 0.66, 1.48; p = .959). Median number of intubation attempts were 2 (interquartile range [IQR]: 1, 3; range: 1, 8) versus 2 (IQR: 1, 3; range 1, 12) (median regression coefficient = 0; 95% CI: -0.7, 0.7; p = .999) and 2 (IQR: 1, 3; range: 1, 12) versus 2 (IQR: 1, 3; range 1, 8) (median regression coefficient = 0; 95% CI: -0.5, 0.5; p = .999). Complication rates were 14% versus 22% (OR 0.6; 95% CI 0.34, 1.04; p = .07) and 16% versus 21% (OR 0.71; 95% CI 0.43, 1.17; p = .185).
CONCLUSIONS: Presence of syndrome was not associated with lower first-attempt success rate on intubation, number of intubation attempts, or complication rate among micrognathic patients difficult to intubate, despite more associated craniofacial abnormalities. Nonsyndromic patients were more likely to have unanticipated difficult intubations, first attempt with direct laryngoscopy.

The pediatric difficult airway is a challenge for the anesthesiologist. In this article, we describe a case where ketamine and dexmedetomidine were used to approach a difficult airway in a five-month-old patient with a palatal teratoma. These two drugs have complementary effects, because of which they can be used to maintain ventilation without compromising airway reflexes and are suitable for the management of pediatric difficult airways.

The laryngeal mask airway (LMA) is recognized as a safe alternative to endotracheal intubation for short-term airway maintenance. In this case report we present the case of a term neonate with upper airway obstruction which was managed with a deflated LMA for 7 consecutive days. Despite previous reports of extended LMA use in neonates without complications, this patient experienced significant pharyngeal mucosal injury and edema, leading to difficulty with subsequent intubation attempts.

Children have unique characteristics that make them particularly vulnerable to perioperative adverse events. Skilled airway management is a cornerstone of high-quality anesthetic management. The use of hybrid airway techniques is a critical tool for the pediatric anesthesiologist. Point-of-care ultrasonography has an expanding role in airway management, from preoperative assessment of airway pathology and gastric contents to confirmation of tracheal intubation and identification of the cricothyroid membrane. The exciting fields of 3-dimensional printing, artificial intelligence, and machine learning are areas of innovation that will transform pediatric difficult airway management in years to come.

The need for safe and quality pediatric anesthesia care in low- and middle-income countries (LMICs) is huge. An estimated 1.7 billion children do not have access to surgical care, and the majority are in LMICs. In addition, most LMICs do not have the requisite surgical workforce including anesthesia providers. Surgery is usually performed at three levels of facilities: district, provincial, and national referral hospitals. Unfortunately, the manpower, equipment, and other resources available to provide surgical care for children vary greatly at the different level facilities. The majority of district level hospitals are staffed solely by non-physician anesthesia providers with variable training and little support to manage complicated pediatric patients. Airway and respiratory complications are known to account for a large portion of pediatric perioperative complications. Management of the difficult pediatric airway pathology is a challenge for anesthesia providers regardless of setting. However, in the low-resource setting poor infrastructure, lack of transportation systems, and crippled referral systems lead to late presentation. There is often a lack of pediatric-sized anesthesia equipment and resources, making management of the local pathology even more challenging. Efforts are being made to offer these providers additional training in pediatric anesthesia skills that incorporate low-fidelity simulation. Out of necessity, anesthesia providers in this setting learn to be resourceful in order to manage complex pathologies with fewer, less ideal resources while still providing a safe anesthetic.

Objective To design and assess an advanced pediatric airway management course, through simulation-based team training and with multiple disciplines, to emphasize communication and cooperation across subspecialties and to provide a common skill set and knowledge base. Methods Trainees from anesthesiology, emergency medicine, critical care, pediatric surgery, and otolaryngology at a tertiary children\'s hospital participated in a 1-day workshop emphasizing airway skills and complex airway simulations. Small groups were multidisciplinary to promote teamwork. Participants completed pre- and postworkshop questionnaires. Results Thirty-nine trainees participated over the 3-year study period. Compared with their precourse responses, participants\' postcourse responses indicated either agreement or strong agreement that the multidisciplinary format (1) helped in the development of team communication skills and (2) was preferred over single-discipline training. Improvement in confidence in managing critical airway situations and in advanced airway management skills was significant ( P < .05). Eighty-one percent of participants had improved confidence in following the hospital\'s critical airway protocol, and 64% were better able to locate advanced airway management equipment. Discussion Multiple subspecialists manage pediatric respiratory failure, where successful care requires complex handoffs and teamwork. Multidisciplinary education to teach advanced airway management, teamwork, and communication skills is practical and preferred by learners and is possible to achieve despite differences in experience. Future study is required to better understand the impact of this course on patient care outcomes. Implications for Practice Implementation of a pediatric difficult airway course through simulation-based team training is feasible and preferred by learners among multiple disciplines. A multidisciplinary approach exposes previously unrecognized knowledge gaps and allows for better communication and collaboration among the fields.

Airway-related tumors in pediatrics are always challenging for anesthesiologists. We present 2 cases of friable, bleeding large tumors in the oral cavity where conventional methods of securing the airway were not possible. Induction of general anesthesia could potentially lead to complete airway collapse and catastrophic obstruction in such cases. Awake fibrotic intubation is limited in pediatric patients. We describe the innovative use of an endotracheal tube inserted blindly as a nasopharyngeal airway guided by end-tidal carbon dioxide trace. This allowed us to bypass the anatomical obstruction and induce anesthesia using sevoflurane in high-flow oxygen. By the described technique, we were able to maintain and assist the spontaneous breathing of the child as well. We also highlight limitations of the use of a conventional nasopharyngeal airway in such situations.

Management of an anticipated difficult airway relies heavily on flexible fiber-optic bronchoscope (FFB) guided awake intubations. In a pediatric patient with difficult airway, doing an awake procedure may be difficult, and hence the child is either deeply sedated or anesthesia is induced before attempting intubation with an appropriate sized FFB. We present the anesthetic management of a 6-year-old child with a lacerated tongue and fractured mandibular condyle, with subsequent inability to open his mouth, who was posted for urgent exploration and open reduction under anesthesia. Unhindered by a damaged pediatric FFB, we innovated by positioning the tip of an adult FFB just outside the larynx, passing a j-tipped guidewire through the working channel of the FFB, and successfully railroaded a naso-tracheal tube over the guidewire. The surgery, reversal and extubation, and the postoperative period were uneventful.