Sir,A 28-day-old child weighing 2.6 kg presented to the pediatric surgeon with complete fusion of upper and lower gums since birth [Figure 1]. Computed tomography scan of temporomandibular joint (TMJ) showed reduced bilateral TMJ space with a fibrous fusion of maxilla and mandible, more on the left side. The TM joints were not ankylosed. There was also micrognathia with retrognathia and right sided cleft in bony palate.
Figure 1
Reduced mouth opening in the infant
Reduced mouth opening in the infantThe child was posted for the release of fibrous synechiae under general anesthesia. She was shifted to the operation theater, with intravenous (IV) line in situ. General anesthesia was planned after nasal fiber optic intubation with local anesthesia and sedation. She was preoxygenated with 100% oxygen for 5 min and injection glycopyrrolate 10 mcg/kg and injection fentanyl 1 mcg/kg were administered intravenously. Local anesthesia was achieved using a nasal MADgic mucosal atomizer device spray with 0.5% lignocaine injected through it. A size 3.0 flexometallic endotracheal tube (ETT) was lubricated well with lignocaine gel and passed through the right naris. Fiber optic intubation was undertaken with a 2.8 mm size fiberscope (KARL STORZ) having a suction channel and an injection port. The fiberscope was passed through the ETT and a “spray as you go technique” was used to anesthetize the upper airway. The vocal cords were visualized, sprayed with 0.5% lignocaine and the fiberscope passed into the trachea until the carina was visualized. The pediatric circuit was attached and after checking for capnographic trace and movement of reservoir bag with respiration, the patient was anesthetized with a mixture of oxygen, nitrous oxide, sevoflurane, and atracurium. Using osteotomes, release of fibrous synechiae was undertaken, mouth opening created and the raw area over the right half of gums was left to heal. The anesthesia was reversed uneventfully.Congenital fusion of the gums is extremely rare and can be of different degrees — mucosal synechiae, fibrous synechiae, and complete bony fusion (syngnathism).[1] It may be associated with other congenital defects such as aglossia, facial hemiatrophy, retrognathia, and cleft palate as were present in our case. Treatment requires surgical separation and depends on the type of fusion. Local anesthesia and intermittent general anesthesia by face mask have been used for mucosal synechiae-release under circumstances where fiber optic intubation was not available.[12]Airway and ventilatory management for surgical separation of the fused jaws under general anesthesia presents severe problems as the laryngeal inlet is very small. Repeated attempts at intubation can injure the delicate airway tissues leading to the emergency requirement of the surgical airway, which by itself is a daunting task in an infant. Seraj et al.[3] used a technique where after induction of the patient with ketamine, a nasopharyngeal airway was inserted, and general anesthesia delivered through a breathing circuit attached to it with the patient breathing spontaneously.Nasal fiber optic intubation is the technique of choice for difficult airway management. Alfery et al.[4] described a technique where a neonate with congenital fusion of gums was given local anesthesia and IV ketamine given in boluses while Lonnée et al. used general anesthesia with sevoflurane to successfully perform nasal fiber optic intubation.[5] Having successfully performed oral intubation under local anesthesia and sedation in an infant with an oral mass we decided to use a similar technique.[6]
Figure 1