globally , an anticipated difficult airway is managed most often with flexible fiberoptic bronchoscope ( ffb)-guided tracheal intubation . in patients with restricted mouth opening , intubation is done through the nasal route , which is unpredictable in terms of the maximum tube size allowable . during ffb - guided intubation , if the preloaded tube is not able to negotiate the nose , most often , the scope is withdrawn to reload a smaller tube , and the procedure is reattempted . in certain situations we present the anesthetic management of five such cases , where we avoided redoing the procedure by using a j - tipped guide wire . we present the anesthetic management of five cases with temporomandibular joint ( tmj ) ankylosis posted for corrective surgery , who presented to our institute over a period of 6 months . all the patients were men in the age group of 1827 years . among the patients all patients had varying degrees of retrognathia , and the maximum thyromental distance recorded was three finger - breadth . nasal patency was judged by keeping a wisp of cotton in front of each nostril , and the nostril with a better air - flow was chosen for intubation . all the patients were asked to fast for 6 h before surgery , and a written , informed consent was taken for awake intubation in view of the difficult airway . in the operation theatre , standard monitors were applied , intravenous ( iv ) line was established , and premedication , consisting of metoclopramide 0.2 mg / kg , glycopyrrolate 5 mcg / kg , and midazolam 10 mcg / kg , was given iv . local anesthesia of the airway was established with a combination of 10% lidocaine spray , nebulization with 4% lidocaine , and superior laryngeal nerve blocks . a difficult airway cart , and equipment and personnel for rapidly establishing a surgical airway were also kept ready . all patients were provided conscious sedation with up to 70% nitrous oxide in oxygen , delivered via a nasopharyngeal airway connected to the anesthesia circuit . a jet ventilator , with its dedicated oxygen source , was kept ready to be connected to the working channel of the ffb and provide 100% oxygen , if required . a 7.5-mm internal diameter ( i d ) flexometallic endotracheal tube ( ett ; lma fastrach ett ) the ett was loaded onto the ffb , and after the successful negotiation of the ffb into the trachea , it was negotiated via the nostril , through the larynx and into the trachea , and finally positioned in front of the carina . in all patients , on attempting to rail - road the ett over the ffb , it was realized that , despite adequate lubrication , the ett could not negotiate the nasal structures . concerned with the difficulty expected in a repeat attempt at bronchoscopy , a 1-mm - thick , 145-cm - long , metallic j - tipped guide wire was threaded through the working channel of the ffb till the carina [ figure 1 ] , and the ffb was then withdrawn , keeping the guide wire in place . a 6.5-mm i d ett was then threaded over the guide wire and negotiated successfully through the nasal passage and other airway structures . after the confirmation of the intratracheal tube position with exhaled carbon dioxide , the ett was fastened , guide wire removed , and induction of anesthesia done . the ffb was used again for visualizing the carina to ensure the precarinal tube position . the patients were monitored for 5 days after the surgery for any airway - related complications and discharged thereafter . ffb - guided nasal intubation under local anesthesia , with the patient breathing spontaneously , is the most commonly performed procedure for airway management in patients with difficult airway , especially those with restricted mouth opening . in the nasal cavity , the widest space for tube passage is along the inferior meatus but this is sometimes encroached upon by a hypertrophied turbinate or deviated nasal septum . during winter months this prevents the passage of a nasal tube , which is otherwise appropriate for age . in case the nasal passage is found to be narrow during fiberoptic - guided intubation , the whole assembly has to be withdrawn to reload a smaller ett . this is undesirable as even minimal trauma during the first intubation attempt causes mucosal bleeding when the mucosa is edematous . we used a 145-cm - long , 1-mm - thick , metallic j - tipped guide wire to assist in rail - roading of the ett after being positioned in the trachea via the working channel of the ffb . the length is crucial and has to be at least 30 cm more than the length of the ffb ( suction port to tip ) to prevent the misplacement of the guide wire [ figure 2 ] . the ffb with the j - tipped guide wire going down its working channel guide wires have played a variety of roles for assisting in tracheal intubation . they have also been inserted in an anterograde fashion through laryngeal mask airways for subsequent endotracheal intubation , and also through ett for changing from oral to nasal route , and for changing the type of ett . rodriguez et al . used a guide wire via the working channel of the ffb for rail - roading of the ett in a case of treacher have reported two cases with a difficult airway , where they left a guide wire in the trachea for assisting in rapid reintubation in the immediate postoperative period , if required . in all our cases , because of the limited mouth opening , the use of supraglottic devices was ruled out . we chose guide wire - aided intubation ahead of blind or light - guided nasal intubation , as we had experience of this technique in patients with a normal airway . if we had failed , we could have gone back to the original plan of attempting an ffb - guided intubation , or could have rapidly established a surgical airway . we feel that the uniquely beveled tip of the lma fastrach ett has a lesser tendency to impinge on the turbinates or the arytenoids , and hence requires adjusting maneuvers less often , apart from causing less trauma . an airway exchange catheter can also be used to reinforce the guide wire before rail - roading the tube to minimize displacement .