Precision in Planning: Airway Battles in Pediatric Temporomandibular Joint Ankylosis

Abstract Background: Pediatric temporomandibular joint (TMJ) ankylosis produces severe trismus, mandibular hypoplasia, and retrognathia, creating an anticipated difficult airway with minimal apnea tolerance. Awake fiberoptic intubation is often impractical in children; therefore, airway strategies must prioritize continuous oxygenation and preservation of spontaneous ventilation. Methods: A consecutive case series of seven pediatric patients with TMJ ankylosis undergoing maxillofacial surgery was analyzed. All underwent inhalational induction with 8% sevoflurane in oxygen while maintaining spontaneous breathing. After nasal preparation, a nasopharyngeal airway connected to a Jackson–Rees circuit delivered anesthetic gases and stented the airway. Fiberoptic nasotracheal intubation was performed via the opposite nostril. Neuromuscular blockade was administered only after capnographic confirmation of tracheal intubation. Airway success and perioperative outcomes were recorded. Results: Patients aged 3 months–7 years had mouth opening ranging from nil to 1 cm. Fiberoptic intubation succeeded in all cases without desaturation, trauma, or failed airway events. Continuous ventilation through the nasopharyngeal airway maintained anesthetic depth and prevented airway collapse during instrumentation. Six patients were extubated awake with uneventful recovery. One infant with Pierre Robin sequence required postoperative ventilation and tracheostomy due to persistent anatomical obstruction rather than intubation failure. Conclusion: Nasopharyngeal airway-assisted inhalational anesthesia followed by fiberoptic nasal intubation is a safe, reproducible primary airway strategy in pediatric TMJ ankylosis. The technique preserves oxygenation, depth of anesthesia, minimizes repeated instrumentation, and is particularly useful in resource-limited settings. Postoperative airway planning remains essential in syndromic infants.