Management of a difficult-to-ventilate and difficult-to-intubate airway: Anesthetists' nightmare.

Sir,

Managing airway in patients with previous extensive facial surgery can be a great challenge to the anesthesiologists. Of paramount importance is prediction and meticulous planning for difficult airway.

A 50-year-old male patient with recurrent mucoepidermoid squamous cell carcinoma of sinonasal cavity and maxilla was scheduled for left total maxillectomy. He underwent extended right total maxillectomy and enucleation of the right eye 3 years ago, following which a big rent in the right hard palate causing huge communicating gap between oral cavity and right orbit was seen [Figure 1a–c]. On examination, the patient had an irregular mass in the left hard palate measuring 5 cm in length involving soft palate and uvula posteriorly and gingivolabial sulcus anteriorly, involving more than half of the oral cavity [Figure 1b]. The patient had adequate mouth opening; thyromental distance and range of motion of the neck were also normal. He had a complete blockade of nasal passage due to tumor growth. Considering the difficult mask ventilation and intubation, awake fiberoptic intubation (AFOI) under conscious sedation was planned to secure airway through the right side of the oral cavity for giving general anesthesia. Computed tomography (CT) of the airway was obtained, and access to the trachea was preevaluated [Figure 1e–g]. A due informed and written consent was obtained. In operating room, difficult airway cart and standby emergency tracheostomy were kept ready. The patient was premedicated with glycopyrrolate 0.4 mg intramuscular; oropharynx and trachea were anesthetized through nebulization with 5 ml of 4% lignocaine, lignocaine 10% topical spray, bilateral superior laryngeal nerve block, and transtracheal injection. The American Society of Anesthesiologists standard monitors were placed to ensure oxygenation during the procedure; a suction catheter attached to the oxygen source with a flow of 10 L/min was advanced toward the glottic opening through the transorbital route.[1] For conscious sedation, injection dexmedetomidine at 1 mcg/kg loading dose was started, and sedation was assessed with the Richmond agitation-sedation scale (RASS).[2] After 10 min, the RASS score was 0–−1, and the dose was decreased to 0.5 mcg/kg/h. Fiberoptic bronchoscope was passed through the right side of the oral cavity, and advanced till carina (spray as you go), followed by railroading-cuffed endotracheal tube (ETT) of size 8.0 mm. The position of the ETT was confirmed by checking bilateral equal air entry and capnography. Anesthesia was induced with propofol (2 mg/kg) and vecuronium (0.1 mg/kg) and maintained with isoflurane in a mixture of 50% oxygen and nitrous oxide. Intraoperative period (2 h) was uneventful; the patient was extubated over a tube exchange catheter, and postoperative course went uneventful [Figure 1d].

Figure 1

(a) defect in right orbit following orbital exenteration. (b) Tumor on the left side of hard palate in oral cavity involving both nasal cavities and rent in the right side of hard palate. (c) Rent in the right side of hard palate leading to communicating gap between oral cavity and right orbit. (d) Image of the patient after excision of the tumor, postoperatively. (e) Computed tomography showing defect in the right side of the face. (f) Computed tomography showing no involvement of larynx and trachea. (g) Computed tomography showing large mass encroaching oral and nasal cavities

In patients with huge maxillofacial defect, the airway can be secured by blind nasal, oral, transorbital, AFOI, or surgical airways. Our patient had a large rent over the right hard palate communicating with right exenterated orbit leading to improper fitting of the mask and air leakage [Figure 1a–c]. Dos Reis Falcao et al. reported a similar type of case with huge facial defect wherein intubation was done through transorbital route.[3] In our case, transorbital and nasal intubation were not possible as nasal openings were blocked and tumor size was large with risk of bleeding. Our patient had received radiation therapy and had distorted airway anatomy mandating preevaluation of airway using CT [Figure 1e–g]. Benumof and Scheller report AOFI as the safest approach for managing predicted difficult airway and decreasing mortality.[4]

Major challenges during AFOI are adequate sedation, maintaining a patent airway, and ensuring adequate spontaneous ventilation. Dexmedetomidine is a potent alpha2 adrenergic receptor agonist with the ability to produce profound sedation without respiratory depression. In addition, it decreases salivary secretion through sympatholytic and vagomimetic effects and causes less hemodynamic instability with better patient tolerance.[56]

Hence, AFOI is an acceptable and safe method of securing the airway, and preevaluation of the airway by using CT provides useful information for planning airway management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.