Intubation Using a “Bonfils Fiberscope” in a Patient With Pfeiffer Syndrome

Abstract

To the Editor: Pfeiffer syndrome is an autosomal dominant disorder characterized by craniosynostosis, brachicephaly, midface hypoplasia, low nasal bridge, flat occiput, severe ocular proptosis, over-sized tongue, and cerebral ventriculomegaly (Fig. 1).1FIGURE 1: A, Computed tomography scan reconstruction of the skull. B, The operator practices the intubation on a mannequin performing upward traction of the mandible by holding it between the left hand thumb and the forefinger.Providing general anesthesia in such patients could lead to complications in terms of airway management, due to potential difficulties in ventilation using the facial mask or tracheal intubation.2 A Bonfils fiberscope is a handy device to overcome difficulties of intubation, both in pediatric patients and in neonates. It is a rigid telescopic stylet with a 40-degree curved tip, which is inserted inside the endotracheal tube, keeping its distal end positioned just proximal to tip of the tube. The proximal eyepiece end of the device allows connections for a video monitor and a fixed or battery-operated light source. The instrument can be easily locked onto an endotracheal tube, while a special connector allows administration of the gases during intubation.3–4 The instrument is available in various sizes and its design makes intubation easy under direct visualization. The main limiting factor for its use is the rigidity, which may increase the risk of airway trauma. Obviously, it cannot be used for nasal intubation. We encountered the case of a 6-year-old patient, weighing 21 kg, who had Pfeiffer and Arnold Chiari syndromes, with caudal migration of cerebral tonsils to the level of the second cervical vertebra. Due to the presence of loud snoring and oxygen desaturation during sleep, the patient was required to undergo adenoidectomy under general anesthesia. The endotracheal intubation was found to be very challenging in this particular case. The induction was carried out with an intravenous administration of fentanyl 60 mcg and propofol 60 mg. At this stage, the anesthesiologist performed upward traction of the patient’s mandible by holding it between the left hand thumb and the forefinger (Fig. 1B) without using the laryngoscope. The Bonfils fiberscope, held in the right hand, was inserted through the oral cavity, the scope preloaded with size 5.5 mm, and the intubation was performed without any difficulty. Our case illustrates that the Bonfils fiberscope allows easy intubation in cases with a complicated upper airway anatomy without requiring a laryngoscope. Some authors do believe, however, that the use of a laryngoscope may be necessary when the Bonfils fiberscope is used in adult patients.5 We recommend that the operator practice the intubation on a mannequin, according to the aforementioned method before the actual procedure. In summary, we find the rigid Bonfils fiberscope a useful device for difficult intubation in pediatric patients with a complex upper airway anatomy. We recommend that this instrument be made available in operatory rooms where pediatric patients undergo general anesthesia. Marco Caruselli, MD Roberto Giretti Roberta Pallotto Giovanni Rocchi Anesthesia and Intensive Care Unit, “Salesi” Children’s Hospital, Ancona Laura Carboni Anesthesia and Intensive Care Unit, “Burlo Garofolo” Children’s Hospital, Trieste, Italy