Anesthetic management of a difficult pediatric airway with fiber-optic bronchoscopy and transnasal humidified rapid-insufflation ventilatory exchange in a case of dentigerous cyst of the mandible

Abstract A dentigerous cyst in the mandible weakens the bone, increasing the risk of pathological fracture during airway manipulation. Fiber-optic bronchoscopy-guided intubation is the safest approach, but it is challenging in children due to poor cooperation. The primary challenge in this case was not anatomical airway difficulty, but the need to avoid mask ventilation and the contraindication to direct laryngoscopy due to a fragile mandible. We present a pediatric patient with a fragile, thinned-out mandible requiring marsupialization. Key concerns include effective topical anesthesia within limits and balancing sedation with spontaneous respiration and preventing mandibular fracture. Topical anesthesia was achieved using nebulized 4% lignocaine, ultrasound-guided superior laryngeal nerve block, and transtracheal injection with 2% lignocaine. Transnasal humidified rapid-insufflation ventilatory exchange was employed via high-flow nasal cannula to maintain oxygenation and avoid mask ventilation, which could have endangered the fragile mandible. An intravenous line was secured postintramuscular ketamine sedation, avoiding inhalational induction to prevent mandibular fracture during mask ventilation. Sedation was maintained with dexmedetomidine and ketamine. Fiber-optic bronchoscope-guided endotracheal intubation was performed successfully without the need for mandibular manipulation.