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1.  One lung ventilation in a patient with an upper and lower airway abnormality 
Indian Journal of Anaesthesia  2012;56(6):567-569.
One-lung ventilation for a thoracotomy procedure was achieved with the help of a endobronchial blocker in a young girl with limited mouth opening, minimal neck extension, and a distorted tracheo-bronchial anatomy. As the patient would not cooperate for an awake nasotracheal intubation despite adequate preperation, an inhalational anesthetic was used to make the patient unconscious, taking care that spontaneous breathing was maintained. Nasotracheal intubation was done with the help of a fiberoptic bronchoscope. A wire-guided Arndt endobronchial blocker was placed coaxially through the endotracheal tube using a fiberoptic bronchoscope. This case report highlights that in a scenario of both upper and lower airway distortion, a bronchial blocker positioned through a nasotracheal tube under fiberoptic guidance might be the best option when one-lung ventilation is required.
doi:10.4103/0019-5049.104578
PMCID: PMC3546245  PMID: 23325943
Bronchoscopy; fiberoptic; Intratracheal intubation; nasotracheal; thoracic surgical procedures
2.  Acute obstruction of an endotracheal tube: a case report. 
Anesthesia Progress  2004;51(2):62-64.
This report describes a case of sudden ventilatory failure, originally diagnosed as bronchospasm, in a child during general anesthesia. A blood clot impaction in the nasotracheal tube was detected using flexible fiberoptic bronchoscopy. The clot was successfully treated as a result of its passage. We hope this report will stress to dental anesthesiologists the intraoperative importance of fiberoptic bronchoscopy not only as an intubation-aiding device but also as a diagnostic and therapeutic tool.
Images
PMCID: PMC2007470  PMID: 15366320
3.  Midline Submental Orotracheal Intubation in Maxillofacial Injuries: A Substitute to Tracheostomy Where Postoperative Mechanical Ventilation is not Required 
Background:
Maxillofacial fractures present unique airway problems to the anaesthesiologist. Nasotracheal intubation is contraindicated due to associated Lefort I, II or III fractures. The requirement for intraoperative maxillomandibular fixation (MMF) to re-establish dental occlusion in such cases precludes orotracheal intubation. Tracheostomy has a high complication rate and in many patients, an alternative to the oral airway is not required beyond the perioperative period. Hernandez1 in 1986 first described “The submental route for endotracheal intubation”. Later some workers faced difficult tube passage, bleeding, and sublingual gland involvement with this approach. They modified this to strict midline submental intubation and there were no operative or postoperative complications in their cases.67&8. Therefore we used mid line approach for submental orotracheal intubation in this study to demonstrate its feasibility and reliability and that it can be used as an excellent substitute to short term tracheostomy.
Patients & Methods:
We used midline submental intubation in 25 cases selected out of 310 consecutively treated patients with maxillofacial trauma over a 3 year period. After induction orotracheal intubation was done with spiral re-inforced tube. A 1.5-2.0 cm skin incision was made in the submental region in the midline 2.0 cm behind the symphysis and endotracheal tube was taken out through this incision in all the cases. At the end of the surgery the procedure was reversed, the submental wound was stitched; all the patients could be extubated & none of them required post-operative mechanical ventilation.
Conclusion:
There were no significant operative or postoperative complications. Postoperative submental scarring was acceptable[6]. We conclude that midline submental intubation is a simple and useful technique with low morbidity. It can be chosen in selected cases of maxillofacial trauma and is an excellent substitute to tracheostomy where postoperative mechanical ventilation is not required.
PMCID: PMC3087271  PMID: 21547178
Submental orotracheal intubation; Maxillofacial injury; Tracheostomy
4.  Usefulness of a Cook® airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation in a neonate with Pierre Robin syndrome -A case report- 
Korean Journal of Anesthesiology  2013;64(2):168-171.
The case of a 33-day-old boy with Pierre Robin syndrome using a Cook® airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation is presented. After induction with sevoflurane, classical reusable laryngeal mask airway (LMA) #1 was inserted and ultrathin fiberoptic bronchoscope (FOB) was passed through. A Cook® airway exchange catheter (1.6 mm ID, 2.7 mm OD) was passed through the LMA under the guidance of the FOB but failed to enter the trachea despite many trials. Then, an endotracheal tube (3.0 mm ID) was mounted on the FOB and railroaded over the FOB. After successful intubation, the Cook® airway exchange catheter was placed in the midtrachea through the lumen of the endotracheal tube. Even though the tracheal tube was accidentally displaced out of the trachea during LMA removal, the endotracheal tube could be easily railroaded over the airway exchange catheter.
doi:10.4097/kjae.2013.64.2.168
PMCID: PMC3581788  PMID: 23458916
Airway exchange catheter; Fiberoptic intubation; Laryngeal mask airway; Pierre robin syndrome
5.  Parker Flex-Tip and Standard-Tip Endotracheal Tubes: A Comparison During Nasotracheal Intubation 
Anesthesia Progress  2010;57(1):18-24.
Abstract
The placement of endotracheal tubes in the airway, particularly through the nose, can cause trauma. Their design might be an important etiologic factor, but they have changed little since their introduction. Recently Parker Medical (Bridgewater, Conn ) introduced the Parker Flex-Tip (PFT) tube, suggesting that it causes less trauma. This study aimed to compare the PFT endotracheal tube to a side-beveled, standard-tip endotracheal tube (ETT) for nasotracheal intubation (Figures 1 and 2). Forty consecutive oral surgery patients requiring nasotracheal intubation were randomized to receive either a standard ETT or the PFT tube. Intubations were recorded using a fiber-optic camera positioned proximal to the Murphy eye of the tube. This allowed visualization of the path and action of the tube tip as it traversed the nasal, pharyngeal, laryngeal, and tracheal airway regions. Video recordings made during intubation and extubation were evaluated for bleeding, trauma, and intubation time. Both bleeding and trauma were recorded using a visual analogue scale (VAS) and by 3 different evaluators. The PFT received significantly better VAS values than the standard tubes from all 3 raters (P < 0.05) in both the extent of trauma and bleeding. Since the intubations were purposefully conducted slowly for photographic reasons, neither tube displayed a time advantage. This study suggests that the PFT tube design may be safer by causing less trauma and bleeding than standard tube designs for nasotracheal intubation.
doi:10.2344/0003-3006-57.1.18
PMCID: PMC2844234  PMID: 20331335
Nasotracheal intubation; Parker Flex-Tip tube; Endotracheal intubation; Endotracheal tube; Fiber-optic intubation
6.  Innovative use of the fiberoptic bronchoscope 
Tracheostomy can be challenging, especially in the presence of edema or infiltrative malignancy. We present a case in which a fiberoptic bronchoscope that is routinely used for difficult intubation helped to locate the trachea in an emergency situation. A 50 year-old male, a diagnosed case of anaplastic carcinoma of thyroid, presented with respiratory distress and was immediately taken to the operating theater for an emergency tracheostomy. Following an inhalational induction, the patient was intubated with an endotracheal tube. Surgical tracheostomy was extremely difficult as, on neck exploration, there was a plaque of disease infiltrating various tissue planes. When even after considerable dissection the trachea could not be located, we passed a fiberoptic bronchoscope through the endotracheal tube. This helped as it was seen as a trans- illumination and the tracheal position could be confirmed. The rest of the tracheostomy was uneventful.
doi:10.4103/0971-5851.107090
PMCID: PMC3618647  PMID: 23580826
Anaplastic carcinoma of thyroid; difficult tracheostomy; fiberoptic bronchoscope
7.  Comparison of oral fiberoptic intubation via a modified guedel airway or a laryngeal mask airway in infants and children 
Background:
Though fiberoptic intubation (FOI) is considered the gold standard for securing a difficult airway in a child, it may be technically difficult in an anesthetized child. The hypothesis for this study was that it would be easier to perform FOI via a laryngeal mask airway (LMA) than a modified oropharyngeal airway with the advantage of maintaining anesthesia and oxygenation during the process.
Materials and Methods:
30 children aged 6 months to 5 years undergoing elective surgery under general anesthesia were randomized to two groups to have fiberoptic bronchoscope (FOB) guided intubation either via a modified Guedel airway (FOB-ORAL) or a classic LMA (FOB-LMA). In the FOB-LMA group, the LMA was removed when a second smaller endotracheal tube was anchored to the proximal end of the tracheal tube in place.
Results:
Oral fiberoptic intubation was successful in all children. The first attempt success rate was 11/15 (73.33%) in the FOB-LMA group and 3/15 (20%) in the FOB-ORAL group (P = 0.012). Subsequent attempts at intubation were successful after 90° anticlockwise rotation of the endotracheal tube over the FOB. The time taken for fiberoptic bronchoscopy was significantly less in FOB-LMA group (59.20 ± 42.85 sec vs 108.66 ± 52.43 sec). The incidence of desaturation was higher in the FOB-ORAL group (6/15 vs 0/15).
Conclusion:
In children, fiberoptic bronchoscopy and intubation via an LMA has the advantage of being easier, with shorter intubation time and continuous oxygenation and ventilation throughout the procedure. Removal of the LMA following intubation requires particular care.
doi:10.4103/0970-9185.105797
PMCID: PMC3590542  PMID: 23493291
Difficult; equipment; fiberoptic bronchoscope; intubation; laryngeal mask airway; modified oropharyngeal Guedel airway; tracheal
8.  Failed nasal intubation after successful flexible bronchoscopy: Guide wire to the rescue 
Flexible fiberoptic bronchoscope-guided awake intubation is the most trusted technique for managing an anticipated difficult airway. Even after successfully negotiating the bronchoscope into the trachea, the possibility remains that the preloaded tracheal tube might prove to be inappropriately large, and may not negotiate the nasal structures. In such a situation, the most obvious solution is to take out the bronchoscope, replace the tracheal tube with a smaller one, and repeat the procedure. Unfortunately, sometimes the second attempt is not as easy as the first, as minor trauma during the earlier attempt causes tissue edema and bleeding, which makes the subsequent bronchoscopic view hazy and difficult. We present the anesthetic management of five cases with temporomandibular joint ankylosis where, after successful, though slightly traumatic, bronchoscope insertion into the trachea, the tube could not be threaded in. We avoided a repeat bronchoscopy by making an innovative change in the plan.
doi:10.4103/0970-9185.83692
PMCID: PMC3161472  PMID: 21897518
Flexible fiberoptic bronchoscope; guide wire; intubation; nasal
9.  GlideScope and Frova Introducer for Difficult Airway Management 
Case Reports in Anesthesiology  2013;2013:717928.
The introduction into clinical practice of new tools for intubation as videolaringoscopia has dramatically improved the success rate of intubation and the work of anesthesiologists in what is considered the most delicate maneuver. Nevertheless intubation difficulties may also be encountered with good anatomical visualization of glottic structures in videolaringoscopia. To overcome the obstacles that may occur both in a difficult provided intubation such as those unexpected, associated endotracheal introducer able to facilitate the passage of the endotracheal tube through the vocal cords into the trachea may be useful. We report 4 cases of difficult intubation planned and unplanned and completed successfully using the GlideScope videolaryngoscope associated with endotracheal Frova introducer.
doi:10.1155/2013/717928
PMCID: PMC3749531  PMID: 23991339
10.  Tracheal laceration during intubation of a double-lumen tube and intraoperative fiberoptic bronchoscopic evaluation through an LMA in the lateral position -A case report- 
Korean Journal of Anesthesiology  2011;60(4):285-289.
A 76-year-old, 148-cm woman was scheduled for right upper lobectomy. A 32 Fr left-sided double lumen tube was placed using a conventional technique. Despite several attempts under fiberoptic bronchoscope-guidance, we could not locate the double lumen tube properly. We thus decided to proceed with the bronchial tube in the right mainstem bronchus. During surgery, 8-cm-long laceration was noted on the posterolateral side of the trachea. To check the possibility of laceration of the proximal trachea, the double lumen tube was changed to an LMA for use as a conduit for fiberoptic bronchoscopic evaluation in the lateral position. A plain endotracheal tube with the cuff modified and collapsed was re-intubated after evaluation. And then she was transferred to SICU.
doi:10.4097/kjae.2011.60.4.285
PMCID: PMC3092965  PMID: 21602980
Fiberoptic bronchoscope; Intubation; Laceration; LMA; Trachea
11.  Placement of a double-lumen tube using LMA C Trach and an exchanger catheter in difficult airway intubation -A case report- 
Korean Journal of Anesthesiology  2012;62(6):565-567.
During insertion of the double lumen tube in patients with cervical vertebral fixation, the cervical neutral position should be maintained. Although flexible fiberoptic bronchoscopic intubation is the gold standard, novel techniques are needed to facilitate intubation of patients with cervical vertebral fixation in neutral position according to institutional capabilities. In this case report, insertion of the double lumen tube in the neutral position using LMA CTrach and an airway exchanger catheter in a thoracotomy patient with extremely limited head and neck motion due to fixation of the cervical vertebrae is presented.
doi:10.4097/kjae.2012.62.6.565
PMCID: PMC3384796  PMID: 22778894
Airway management; Difficult airway; Equipment; Laryngeal masks; Lung separation
12.  Warming Endotracheal Tube in Blind Nasotracheal Intubation throughout Maxillofacial Surgeries 
Introduction: Blind nasotracheal intubation is an intubation method without observation of glottis that is used when the orotracheal intubation is difficult or impossible. One of the methods to minimize trauma to the nasal cavity is to soften the endotracheal tube through warming. Our aim in this study was to evaluate endotracheal intubation using endotracheal tubes softened by hot water at 50 °C and to compare the patients in terms of success rate and complications.
Methods: 60 patients with ASA Class I and II scheduled to undergo elective jaw and mouth surgeries under general anesthesia were recruited.
Results: success rate for Blind nasotracheal intubation in the control group was 70% vs. 83.3% in the study group. Although the success rate in the study group was higher than the control group, this difference was not statistically significant. The most frequent position of nasotracheal intubation tube was tracheal followed by esophageal and anterior positions, respectively.
Conclusion:In conclusion, our study showed that using an endotracheal tube softened by warm water could reduce the incidence and severity of epistaxis during blind nasotracheal intubation; however it could not facilitate blind nasotracheal intubation.
doi:10.5681/jcvtr.2013.032
PMCID: PMC3883537  PMID: 24404345
Blind Intubation; Warming; Endotracheal Tube; Oral and Maxillofacial Surgery; Anesthesia
13.  Thermosoftening of the Parker Flex-TipTM Tracheal Tube in Preparation for Nasotracheal Intubation 
Anesthesia Progress  2013;60(3):109-110.
The Parker Flex-Tip tracheal tube (PFTT, Parker Medical, Highlands Ranch, Colo) has a soft, flexible, curved tip with double Murphy eyes. Previous studies have shown that the PFTT reduces the incidence of epistaxis during nasotracheal intubation and the incidence of postintubation nasal pain, as compared to conventional tracheal tubes. Although thermosoftening is a well-known and effective technique for reducing epistaxis during nasotracheal intubation with conventional tracheal tubes, we occasionally encounter difficulties with advancing the tube through the nasal passage when the PFTT is thermosoftened prior to nasotracheal intubation. Consequently, when using the PFTT for nasotracheal intubation, the procedure of thermosoftening should be avoided.
doi:10.2344/0003-3006-60.3.109
PMCID: PMC3771198  PMID: 24010988
Thermosoftening; Tracheal tubes
14.  Comparison of endotracheal intubation techniques in llamas 
The Canadian Veterinary Journal  2009;50(7):745-749.
This study evaluated a retrograde orotracheal intubation technique and compared it to the traditional normograde intubation technique used in llamas. Oral anatomical features, which can impair visualization of the epiglottis and laryngeal structures, and the production of excessive salivary secretions make it difficult to establish an airway under emergency conditions. Normograde intubation involves placing a stylet through the mouth into the trachea and advancing the endotracheal tube over the stylet into the trachea. For retrograde intubation, a nested trochar with cannula is placed into the cervical trachea and a stylet is advanced through the cannula and out the mouth. The endotracheal tube is advanced over the stylet back into the trachea. Our evaluation of both techniques found no statistical difference in time to place the stylet or endotracheal tube; however, fewer attempts were needed to place the tube using the retrograde technique. We found the retrograde technique to be a viable option for intubating llamas.
PMCID: PMC2696706  PMID: 19794871
15.  Evaluation of Inter Incisal Mouth Opening for Airway Maintenance in Oral Submucous Fibrosis 
Purpose
Determination of difficult airway maintenance preoperatively holds a great significance in different intubation techniques and also surgical exploration of airway. No data is available for relation of airway maintenance and preoperative interincisal mouth opening in oral submucous fibrosis patients.
Methods
20 oral submucous fibrosis patients were evaluated pre operatively for general anaesthesia. Direct nasotracheal intubation, fiberoptic laryngoscopy guided intubation or awake blind nasal intubation technique, or combination of above techniques were used.
Results
Mean pre operative inter incisal mouth opening for direct nasotracheal intubation (nine patients) is 15.44 mm, fiberoptic guided laryngoscopy (six patients) is 9.0 mm and blind nasal intubation (five patients) is 5.2 mm.
Conclusion
Benefits of avoiding a surgical exploration of airway was significant.
doi:10.1007/s12663-012-0337-y
PMCID: PMC3428452  PMID: 23997480
Pre operative inter incisal mouth opening; Direct nasotracheal intubation; Fiberoptic guided laryngoscopy; Awake blind nasal intubation; Oral submucous fibrosis
16.  Airway Management in Croup and Epiglottitis 
Western Journal of Medicine  1977;126(3):184-189.
Treatment techniques for airway obstruction in croup and epiglottitis are reviewed in the medical literature. Series totaling 295 nasotracheal intubations, and 591 tracheostomies were reviewed. There were two deaths attributable to airway complications in 126 patients in whom nasotracheal intubation was carried out. In three patients subglottic granulation tissue and subglottic stenoses developed from short-term nasotracheal intubation. There were no subglottic stenoses or tracheal stenoses reported in the 591 tracheostomies. From this review, it would seem feasible to use nasotracheal intubation for short-term airway treatment in croup and epiglottitis. The increasing occurrence of laryngeal and tracheal complications with long-term intubation suggests that tracheostomy be considered in such cases.
PMCID: PMC1237501  PMID: 349884
17.  Successful tracheal intubation using fiberoptic bronchoscope via an I-gel™ supraglottic airway in a pediatric patient with Goldenhar syndrome -A case report- 
The I-gel™ is a single-use supraglottic airway device introduced in 2007 which features a non-inflatable cuff and allows passage of a tracheal tube owing to its large diameter and short length of the airway tube. In this case, the authors experienced a difficult airway management on a 4-year-old boy with underlying Goldenhar syndrome who underwent a tonsillectomy. Intubation using a laryngoscope was unsuccessful at the first attempt. In the following attempt, we used the I-gel™ supraglottic airway for ventilation and were able to achieve successful intubation with a cuffed tube by using fiberoptic bronchoscope through the I-gel™ supraglottic airway. The authors suggest that I-gel™ is a useful device for ventilation and it has many advantages for tracheal intubation in pediatric patients with difficult airway.
doi:10.4097/kjae.2013.65.1.61
PMCID: PMC3726849  PMID: 23904941
Airway management; Fiberoptic bronchoscope; Goldenhar syndrome; Laryngeal mask airway; Pediatric
18.  "Detachment of the carinal hook following endobronchial intubation with a double lumen tube" 
BMC Anesthesiology  2011;11:20.
Background
Carinal hooks increases difficulty at endotracheal intubation. Amputation of the carinal hook during passage and malpositioning of the tube to the hook are some of the potential problems related with left-sided Carlens double lumen tube (DLT). This article reports an amputation of the hook during a difficult selective intubation and aimed at calling the attention to complications associated with DLTs and the importance of fiberoptic bronchoscopy.
Case presentation
A 68 year-old woman was scheduled for right-sided thoracotomy in whom blind DLT insertion was performed. Narrowed trachea causes difficulty in rotating the DLT 90° counter-clockwise. After carinal hook was noticed upon visual inspection of the DLT, fiberoptic bronchoscopy was used to remove the missing part (with the use of forceps) from the right mainstem bronchus.
Conclusion
Insertion of DLTs with carinal hook is associated with technical problems and potentially life-threatening hazards have discouraged their use. Fiberoptic evaluation and repositioning solves most of the problems. Although amputation of the carinal hook has not been previously reported, clinicians should be alert. This case report emphasizes the utility of the fiberoptic bronchoscopy in the operating theatre for placement, positioning and inspection of the carinal hook DLT.
doi:10.1186/1471-2253-11-20
PMCID: PMC3229443  PMID: 22035156
19.  Application of Gum Elastic Bougie to Nasal Intubation 
Anesthesia Progress  2010;57(3):112-113.
Gum elastic bougie (GEB), a useful device for difficult airway management, has seldom been used for nasotracheal intubation. Among 632 patients undergoing dental procedures or oral surgery, GEB was used successfully in 16 patients in whom conventional nasal intubation had failed because of anatomical problems or maldirection of the tip of the tracheal tube. We recommend that GEB should be applied from the first attempt for nasal intubation in patients with difficult airways.
PMCID: PMC3315278  PMID: 20843227
Gum elastic bougie; Nasal intubation; Difficult intubation
20.  Dual Bougie Technique for Nasotracheal Intubation 
Anesthesia Progress  2012;59(2):85-86.
We read with great interest the anesthetic technique of using a gum elastic bougie (GEB) for nasal intubation in a recent issue of Anesthesia Progress. The authors recommend the use of GEB for the first attempt of nasotracheal intubation in patients with a difficult airway. We agree that this is an excellent alternative. We also have found an excellent variation of this method that utilizes a double bougie technique for insertion of a nasotracheal tube if the difficult airway can be secured initially with an orotracheal tube.
doi:10.2344/11-09.1
PMCID: PMC3403587  PMID: 22822996
Dual bougie technique; Nasotracheal intubation
21.  Increased success of blind nasotracheal intubation through the use of nasogastric tubes as a guide. 
Anesthesia Progress  1996;43(2):58-60.
We were able to improve the success rate of blind nasotracheal intubation by using nasogastric tubes as a guide during intubation, first, for passing the endotracheal tube through the nasal cavity, and second, passing it from the pharynx to the larynx. By adding both sedation by modified neuroleptanalgesia (NLA) and topical and transtracheal administration of lidocaine, our technique became safer and smoother. We have completed 36 cases without accident, with an average time for intubation of 8.25 min. The Rüsh spiral tube was thought to be the most suited to this form of intubation because of the 90 degrees cut of its tip, its high-volume cuff, and its flexibility in all directions. These features are useful for hearing breath sounds, raising the tip of the tube by inflation of the cuff, and advancing the tube in a turning motion.
PMCID: PMC2148780  PMID: 10323127
22.  Foot length, an accurate predictor of nasotracheal tube length in neonates 
BACKGROUND—Existing guidelines for optimal positioning of endotracheal tubes in neonates are based on scanty data and relate to measurements that are either non-linear or poorly reproducible in sick infants. Foot length can be measured simply and rapidly and is related to a number of external body measurements.
OBJECTIVES—To evaluate the relation of foot length to nasotracheal length in direct measurements at post mortem examinations, and then compare its clinical relevance with traditional weight based estimates in a randomised controlled trial.
METHODS—The dimensions of the upper airway were measured at autopsy in 39 infants with median (range) postmenstrual age and birth weight of 32 (24-43) weeks and 1630 (640-3530) g. The regression equations with 95% prediction intervals were calculated to estimate the optimal nasotracheal length from foot length. In a randomised trial, 59 neonates were nasally intubated according to foot length and body weight based estimates to assess the achievement of "optimal" and "satisfactory" tube placements.
RESULTS—In the direct measurements of the airway at autopsy, foot length was a better predictor of nasotracheal distances (r2 = 0.79) than body weight, gestational age, and head circumference (r2 = 0.67, 0.58, and 0.60 respectively). Measurement of foot length was easy and highly reproducible. In the randomised controlled trial, there were no significant differences between the foot length and body weight based estimates in the rates of optimal (44% v 56%) and satisfactory (83% v 72%) endotracheal tube placements.
CONCLUSIONS—Foot length is a reliable and reproducible predictor of nasotracheal tube length and is at least as accurate as the conventional weight based estimation. This method may be particularly valuable in sick unstable infants.


doi:10.1136/fn.85.1.F60
PMCID: PMC1721291  PMID: 11420326
23.  Cuff Inflation to Aid Nasotracheal Intubation Using the C-MAC Videolaryngoscope 
Ghana Medical Journal  2011;45(2):84-86.
Summary
A preliminary report is presented of a technique for using the C-MAC videolaryngoscope to carry out nasopharyngeal intubations. The main thrust of the technique is that cuff inflation of the endotracheal tube is used to lift the endotracheal tube off the posterior pharyngeal wall and thus direct it towards the glottis. The technique was used successfully in 5 consecutive patients needing nasotracheal intubation. Indeed a couple of these patients might have been difficult to intubate using conventional laryngoscopy. The full technique is described together with pictures at the various stages of intubation.
PMCID: PMC3158534  PMID: 21857727
Cuff inflation; C-MAC videolaryngoscope; nasotracheal intubation; difficult intubation
24.  Severe upper airway obstruction due to delayed retropharyngeal hematoma formation following blunt cervical trauma 
BMC Anesthesiology  2007;7:2.
Background
We report a case of severe upper airway obstruction due to a retropharyngeal hematoma that presented nearly one day after a precipitating traumatic injury. Retropharyngeal hematomas are rare, but may cause life-threatening airway compromise.
Case presentation
A 50 year-old man developed severe dyspnea with oropharyngeal airway compression due to retropharyngeal hematoma 20 hours after presenting to the emergency department. The patient also had a fractured first cervical vertebra and was diagnosed with a left brachial plexopathy. The patient underwent emergent awake fiberoptic endotracheal intubation to provide a definitive airway.
Conclusion
Retropharyngeal hematoma with life-threatening airway compromise can develop hours or days after a precipitating injury. Clinicians should be alert to the potential for this delayed airway collapse, and should also be prepared to rapidly secure the airway in this patient population likely to have concomitant cervical spinal or head injuries.
doi:10.1186/1471-2253-7-2
PMCID: PMC1828150  PMID: 17352800
25.  Airway management of a difficult airway due to prolonged enlarged goiter using loco-sedative technique 
Saudi Journal of Anaesthesia  2013;7(1):86-89.
Appropriate airway management is an essential part of anesthesiologist's role. Huge goiters can lead to distorted airway and difficulty in endotracheal intubation. In this report, we present a case of a 67-year-old woman with a huge toxic multinodular thyroid swelling, gradually increasing in size for last 20 years, where trachea was successfully intubated. She had a history of deferred surgery in June 2007 due to inability to intubate, despite 5-6 attempts using different laryngoscopes, bougie, and stylet. Patient was re-admitted in December 2011 for the surgery and was successfully intubated this time with help of fiberoptic intubation using loco-sedative technique. Patient was electively kept intubated postoperatively in view of chances of tracheomalacia due to prolonged large goiter. She was extubated successfully on post-op day 2 after demonstration of leak around trachea following tracheal tube cuff deflation. The different techniques of managing the difficult airway in these patients are discussed.
doi:10.4103/1658-354X.109829
PMCID: PMC3657934  PMID: 23717240
Difficult airway; fiberoptic intubation; huge thyroid

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