To the Editor:—

Anesthesiologists are occasionally faced with patients who develop a seriously compromised ability to open their mouths due to previous otolaryngeal operations, which often prevents conventional intubation. We are reporting the case of a patient with a frozen temporomandibular joint due to a previous radical resection of a maxillary carcinoma with orbital exenteration, who could only be fiberoptically intubated via  his orbit. This 49-yr-old man was scheduled for closure of a fistula between the oral cavity and the maxillary sinus. A nasal and oral fiberoptic approach was not possible because of excessive scarring in the patient's nasopharynx and due to a frozen temporomandibular joint. Therefore, the only possible way to avoid tracheotomy was fiberoptically-guided intubation through the patient's orbit. We decided to perform awake fiberoptic intubation to maintain spontaneous breathing throughout the whole procedure. After adequate premedication the bronchoscope was prepared with an 8.5 mm endotracheal tube and inserted into the orbit. It was easily passed through the neo-maxillary sinus into the larynx. After visualization of the vocal cords the 8.5 mm endotracheal tube was placed without any difficulty into the trachea with the 25 cm mark at the edge of the orbit (fig. 1). The patient was breathing spontaneously and oxygen saturation remained at 100% throughout the procedure.

To the best of our knowledge this is the first time that a fiberoptically-guided intubation, using the orbit and maxillary sinus to access the trachea, has been reported. There have only been two reports of similar approaches to the patient's airway after head and neck surgery. However, in the case of Brusis and Hoeppner 1as well as in the case of Foroughi et al ., 2general anesthesia was induced before the airway was secured. This does not seem to be state of the art, because if there are indications that ventilation via  facemask might be insufficient or even impossible, the main advantage in the spontaneously breathing patient is that the procedure can safely be discontinued if the attempt fails. 3Thus, the orbital approach in the spontaneous breathing patient was the easiest, safest, and also most convenient way of intubation.

In conclusion, the technique we describe for the first time offers safe and elegant airway management for patients with a frozen temporomandibular joint and airway alterations, including a communication between the orbit and the larynx. This case reminds the anesthesiologist that a full understanding of prior head and neck surgery can lead to case-specific insights about airway management that may be superior to conventional approaches.

Brusis T, Hoppner J: Eine ungewöhnliche Intubation (letter). Anaesthesist 1975; 24: 461
Foroughi V, Williams EL, Ferrari HA: Transorbital endotracheal intubation after maxillectomy and orbital exenteration. Anesth Analg 1994; 79: 801–2
Benumof JL: Management of the difficult adult airway. A nesthesiology 1991; 75: 1087–110