Systematic Approach to Awake Fibreoptic Intubation in a Post-Hemi-Mandibulectomy Patient with Distorted Airway Anatomy

Subha Jose Vazhakalayi; Kshitija Devendra Bora; Sravya Bejugama

doi:10.5455/JSRR.20250703081705

Abstract
Managing the airway in patients with previous head and neck surgeries can be particularly challenging, especially when significant anatomical distortion and restricted mouth opening are present. We describe the case of a 38-year-old man with a history of hemi-mandibulectomy, scheduled for wide local excision and neck dissection with flap reconstruction. Given the difficult airway anticipated, we opted for an awake fibreoptic nasotracheal intubation. A careful, stepwise approach was followed—starting with thorough airway topicalization using nebulized, sprayed, and transtracheal lignocaine, combined with mild sedation for comfort. The fibreoptic bronchoscope provided continuous visualization of the airway, allowing for smooth passage of the endotracheal tube while maintaining spontaneous ventilation. The intubation was successful on the first attempt, and the surgery proceeded without any airway-related issues. This case highlights how thoughtful preparation, effective airway anesthesia, and a structured plan are key to safely managing complex airways, particularly in patients with head and neck pathology.

Key words: Difficult airway, awake fibreoptic intubation, head and neck surgery, distorted airway anatomy, airway topicalization, nasotracheal intubation, mandibulectomy