Type II Genial Tubercle Fracture

Type II genial tubercle fracture, associated with traumatic mandibular fracture, may cause life-threatening airway compromise. In a case of a 12-yr-old boy with traumatic comminuted mandibular fracture, after anesthesia induction, hypoxia rapidly developed due to a limited view during direct laryngoscopy, intraoral bleeding, resistance to jaw thrust, and subsequent mask ventilation failure. Three-dimensional computed tomography scans (fig. 1, A to C) revealed a detached genial tubercle (white arrows).

The genial tubercle, as the insertion point for genioglossus and geniohyoid muscles, is essential for maintaining the tongue and hyoid’s anatomical position. Traumatic genial tubercle fracture typically retracts the tongue and hyoid into the pharynx, increasing the risk of pharyngeal airway obstruction. Floor of mouth edema, posterior–inferior tongue displacement, and inferior hyoid displacement were evident in prereduction computed tomography (fig. 1C) in contrast to postreduction (fig. 1D).

For traumatic mandibular fracture, anesthesiologists should be aware of potential concomitant genial tubercle fracture and assess the extent of injuries by reviewing preoperative imaging with their surgical team. As three-dimensional computed tomography facilitates diagnosis, the inferior hyoid displacement below C3 level in adults and C2–3 in children under 11 yr could be a predictor of difficult intubation.  After diagnosis, patients should be kept under continuous airway monitoring. Early endotracheal intubation and timely surgical reduction of the fracture are indicated when airway patency is a concern. In airway management, flexible bronchoscopy intubation is recommended to maintain spontaneous ventilation and minimize the risk of secondary injuries associated with intubation. Additionally, having an emergency tracheostomy team on standby is crucial.