Difficulty laryngoscopy and failed nasotracheal intubation in patient presenting fibrous dysplasia: A case report

Fibrous dysplasia is a disorder characterized by excessive proliferation of bone-forming mesenchymal cells. We describe a case of fibrous dysplasia that caused difficult laryngoscopy and failed nasotracheal intubation. A 32-year-old female who presented with polyostotic fibrous dysplasia of the costal bones, left maxilla and mandibula with facial asymmetry was scheduled for conservative osteotomy of the mandibula under general anesthesia (Fig. 1, 2). On physical assessment, the patient had a Class Mallampati view with two finger width of mouth opening and could not thrust her jaw forward. Preoperative computed tomographic (CT) images, multislice three-dimensional CT images and magnetic resonance images (MRI) showed osteosclerosis and ground glass appearance of the costal bones and the left side of the skull including the maxillary bone, mandibular bone and zygomatic bone. There was obstruction of the left paranasal sinus and nasal cavity but no significant radiological abnormality of the right nasal cavity (Fig. 3). Inhalation anesthesia was induced with intravenous propofol (80 mg) and inhalation of 1.5% sevoflurane in oxygen. Following confirmation of mask ventilation, laryngoscopy was attempted. Direct laryngoscopy using a Macintosh blade #3 proved difficult and resulted in impaired insertion of the tip into the pharyngeal space, but indirect laryngoscopy was achieved using the GlideScope video laryngoscope (GVL®3). The endotracheal tube was inserted into the trachea via the mouth, and then nasotracheal intubation was attempted. The 8.0 mm ID polyvinyl chloride endotracheal tube could not be passed into the right nostril, so a 7.0 mm ID tube was substituted and inserted into the trachea. High airway resistance was observed and the tube was removed. The part of the tube that was positioned in the nasal cavity was apparently compressed. Then a 7.0 mm ID partially reinforced tube for nasotracheal intubation was inserted into the trachea, but the cuff did not inflate due to compression of the lumen. Nasotracheal intubation was aborted, and volume reduction surgery of the mandible proceeded uneventfully under orotracheal intubation. This case indicates that facial fibrous dysplasia could cause difficulty with laryngoscopy and obstruction of the tube in the nasal cavity during nasotracheal intubation. The application of GlideScope video laryngoscope may contribute to successful laryngoscopy in a patient with limited tongue space. Preoperative examination of the skull using CT or MRI is essential to determine airway management during anesthesia in patients with facial fibrous dysplasia.