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Background: In resource-limited settings, advanced airway management tools like fiberoptic bronchoscopes are often unavailable, creating challenges for managing difficult airways. We present the case of a 25-year-old male with post-burn contractures of the face, neck, and thorax in Nigeria, who had been repeatedly denied surgery due to the high risk of airway management complications. This case highlights how an awake intubation was safely performed using an Airtraq® laryngoscope, the only device available, as fiberoptic intubation was not an option. The patient had a mouth opening of 3.5 cm, a Mallampati score of 4, and no neck extension, making intubation challenging. Pre-procedural counseling was provided, and after explaining the risks, the patient gave informed consent. Case presentation: Preoxygenation was performed, followed by topical anesthesia using lidocaine gargles and incremental spraying of lidocaine to the vocal cords via a feeding tube. The Airtraq® laryngoscope enabled glottic visualization despite limited neck mobility and challenging anatomy. Procedural challenges included managing aspiration during gargling, precise lidocaine application without advanced tools, and maintaining patient cooperation. The procedure was successfully completed, allowing surgery for contracture release. Conclusions: This case emphasizes that safe awake intubation with an Airtraq® laryngoscope is feasible in low-resource environments when key principles—oxygenation, topical anesthesia, and careful procedural steps—are followed. The reuse of a single-use device like the Airtraq® laryngoscope extends its utility in resource-constrained settings, enabling complex airway management when alternatives are unavailable. The patient tolerated the procedure well and reported minimal discomfort. This experience underscores the critical importance of innovation, resourcefulness, and patient cooperation in managing difficult airways when standard tools are unavailable, offering valuable lessons for similar resource-constrained environments. [ABSTRACT FROM AUTHOR]

Summary: Background: Different sedation regimens have been used to facilitate awake tracheal intubation, but the evidence has not been synthesised robustly, particularly with respect to clinically important outcomes. We conducted a systematic review and network meta‐analysis to determine the sedation techniques most likely to be associated with successful tracheal intubation, a shorter time to successful intubation and a lower risk of arterial oxygen desaturation. Methods: We searched for randomised controlled trials of patients undergoing awake tracheal intubation for any indication and reporting: overall tracheal intubation success rate; tracheal intubation time; incidence of arterial oxygen desaturation; and other related outcomes. We performed a frequentist network meta‐analysis for these outcomes if two or more sedation regimens were compared between included trials. We also performed a sensitivity analysis excluding trials with a high risk of bias. Results: In total, 48 studies with 2837 patients comparing 33 different regimens were included. Comparing overall awake tracheal intubation success rates (38 studies, 2139 patients), there was no evidence suggesting that any individual sedation regimen was superior. Comparing times to successful tracheal intubation (1745 patients, 24 studies), any sedation strategy was superior to placebo. When we excluded trials with a high risk of bias, we found no evidence of a difference between any interventions for time to successful tracheal intubation. Thirty‐one studies (1753 patients) suggested that dexmedetomidine and magnesium sulphate were associated with a reduced risk of arterial oxygen desaturation compared with other interventions, but excluding trials with a high risk of bias suggested no relevant differences between interventions. The quality of evidence for each of our outcomes was low. Conclusions: To maximise effective and safe awake tracheal intubation, optimising oxygenation, topical airway anaesthesia and procedural performance may have more impact than any given sedation regimen. [ABSTRACT FROM AUTHOR]

Background There have been numerous advancements in airway equipment since the flexible fiberoptic bronchoscope was initially used. Clinicians must be aware of the functions and constraints of the equipment that is currently on the market in order to make the best decisions. Poor judgment combined with the wrong equipment selection was revealed to be a contributing factor in airway morbidity and mortality in the United Kingdom's Fourth National Audit Project. For the evaluation, diagnosis, and treatment of patients with respiratory diseases, flexible bronchoscopy (FB) is a common and safe procedure. Since Facebook was first created in 1967, its process and applications have gradually changed and grown. The fiberoptic intubation technique involves passing a tracheal tube loaded along its length through the glottis to enable for a flexible oral or nasal route that clearly visualizes the vocal cords. The endoscope is then removed once the tracheal tube has been inserted into the trachea. Conclusions Awake fiberoptic intubation is widely advocated for the management of the known or anticipated difficult airway. However, fiberoptic intubation can be a challenging technique to learn, and continuous practice is needed to maintain the skill. [ABSTRACT FROM AUTHOR]

Abstract Background Different approach ultrasound-guided superior laryngeal nerve block was used to aid awake intubation, but little is known which approach was superior. We aimed to compare the parasagittal and transverse approaches for ultrasound-guided superior laryngeal nerve block in adult patients undergoing awake intubation. Methods Fifty patients with awake orotracheal intubation were randomized to receive either a parasagittal or transverse ultrasound-guided superior laryngeal nerve block. The primary outcome was patient’s quality of airway anesthesia grade during insertion of the tube into the trachea. The patients’ tube tolerance score after intubation, total procedure time, mean arterial pressure, heart rate, Ramsay sedation score at each time point, incidence of sore throat both 1 h and 24 h after extubation, and hoarseness before intubation, 1 h and 24 h after extubation were documented. Results Patients’ quality of airway anesthesia was significantly better in the parasagittal group than in the transverse group (median grade[IQR], 0 [0–1] vs. 1 [0–1], P = 0.036). Patients in the parasagittal approach group had better tube tolerance scores (median score [IQR],1[1–1] vs. 1 [1–1.5], P = 0.042) and shorter total procedure time (median time [IQR], 113 s [98.5–125.5] vs. 188 s [149.5–260], P

The laryngeal adductor reflex (LAR) is a brainstem reflex that closes the vocal fold and constitutes a new method for continuously monitoring the vagus and laryngeal nerves during different surgeries. Previous reports concluded that topical lidocaine in spray inhibited LAR responses. However, topical anesthesia in the upper airway may be necessary in awake intubation. We present six patients who underwent neck endocrine surgery due to an intrathoracic goiter that compromised the airway. Before awake intubation, a nebulization of lidocaine 5% was applied for at least 10 min. The intubation procedure was well tolerated, and bilateral LAR with suitable amplitudes for monitoring was obtained in all cases. In our series, the nebulization of lidocaine 5% did not affect the laryngeal adductor reflex. Laryngoscope, 134:4161–4164, 2024 [ABSTRACT FROM AUTHOR]

Background: Different approach ultrasound-guided superior laryngeal nerve block was used to aid awake intubation, but little is known which approach was superior. We aimed to compare the parasagittal and transverse approaches for ultrasound-guided superior laryngeal nerve block in adult patients undergoing awake intubation. Methods: Fifty patients with awake orotracheal intubation were randomized to receive either a parasagittal or transverse ultrasound-guided superior laryngeal nerve block. The primary outcome was patient's quality of airway anesthesia grade during insertion of the tube into the trachea. The patients' tube tolerance score after intubation, total procedure time, mean arterial pressure, heart rate, Ramsay sedation score at each time point, incidence of sore throat both 1 h and 24 h after extubation, and hoarseness before intubation, 1 h and 24 h after extubation were documented. Results: Patients' quality of airway anesthesia was significantly better in the parasagittal group than in the transverse group (median grade[IQR], 0 [0–1] vs. 1 [0–1], P = 0.036). Patients in the parasagittal approach group had better tube tolerance scores (median score [IQR],1[1–1] vs. 1 [1–1.5], P = 0.042) and shorter total procedure time (median time [IQR], 113 s [98.5–125.5] vs. 188 s [149.5–260], P < 0.001) than those in the transverse approach group. The incidence of sore throat 24 h after extubation was lower in the parasagittal group (8% vs. 36%, P = 0.041). Hoarseness occurred in more than half of the patients in parasagittal group before intubation (72% vs. 40%, P = 0.023). Conclusions: Compared to the transverse approach, the ultrasound-guided parasagittal approach showed improved efficacy in terms of the quality of airway topical anesthesia and shorter total procedure time for superior laryngeal nerve block. Trial registration: This prospective, randomized controlled trial was approved by the Ethics Committee of Nanjing First Hospital (KY20220425-014) and registered in the Chinese Clinical Trial Registry (19/6/2022, ChiCTR2200061287) prior to patient enrollment. Written informed consent was obtained from all participants in this trial. [ABSTRACT FROM AUTHOR]

Pleural tumours represent a small yet significant subset of thoracic malignancies. Solitary Fibrous Tumours of the Pleura (SFTPs) are typically benign and account for 5% of all pleural tumours. Authors report a case of SFTPs excision with a postoperative diagnosis of Doege Potter Syndrome (DPS) in a 63-year-old male patient who was referred with complaints of chronic productive cough and breathlessness. Upon clinical and radiological evaluation, he was diagnosed with SFTPs. The patient experienced preoperative and intraoperative hypoglycaemic episodes, which were diagnosed as DPS during postoperative evaluation. This syndrome is a paraneoplastic condition associated with the secretion of Insulin-like growth factor-2 (IGF-II), observed in less than 5% of patients with SFTPs, with hypoglycaemia being a major symptom. Awake intubation and other procedures were performed with the patient in a propped-up position as he was unable to lie supine, which caused dyspnoea.

Summary: Patients with facial trauma are complex; difficult airway management is often anticipated and challenging for the anaesthetist. Awake tracheal intubation is the gold standard in the management of predicted difficult airway because of its high success rate and safety profile. We present the case of a patient with facial trauma who underwent orotracheal intubation with combined videolaryngoscopy and flexible bronchoscopy, under conscious sedation with intermittent boluses of ketamine and dexmedetomidine. Videolaryngoscopy showed significant oedema and epiglottic laceration, not diagnosed by the computed tomography scan, with visualisation of a false passage that could have led to a failed intubation and further trauma. Airway management in patients with facial trauma is challenging and should be planned and discussed by a multidisciplinary team. A technique combining videolaryngoscopy and flexible bronchoscopy during awake intubation has previously been described and, when used in this case, was successful. [ABSTRACT FROM AUTHOR]

Background: In recent years, videolaryngoscopy has increasingly been utilized as an alternative to fiberoptic bronchoscopy in awake intubation. Nonetheless, it remains uncertain whether videolaryngoscopy represents a viable substitute for fiberoptic bronchoscopy. We conducted this systematic review with a meta-analysis to compare videolaryngoscopy and fiberoptic bronchoscopy for awake intubation. Methods: We systematically searched for all randomized controlled trials (RCTs) comparing videolaryngoscopy and fiberoptic bronchoscopy for awake intubation. The Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE were systematically queried through August 2023. Our primary outcome measure was the duration of intubation. Secondary outcomes encompassed the rate of successful intubation on the initial attempt, failed intubation, patient-reported satisfaction, and any complications or adverse events potentially stemming from the intubation procedure. The Cochrane Risk of Bias Tool for RCTs was employed to evaluate all studies for evidence of bias. The GRADE approach was utilized to gauge the certainty of the evidence. Results: Eleven trials involving 873 patients were ultimately included in our review for data extraction. Meta-analysis demonstrated that videolaryngoscopy decreased the duration of intubation compared to fiberoptic bronchoscopy (SMD −1.9671 [95% CI: −2.7794 to −1.1548] p < 0.0001), a finding corroborated in subgroup analysis by the type of videolaryngoscope (SMD −2.5027 [95% CI: −4.8733 to −0.1322] p = 0.0385). Additionally, videolaryngoscopy marginally lowered the risk of experiencing a saturation below 90% during the procedure (RR −0.7040 [95% CI: −1.4038 to −0.0043] p = 0.0486). No statistically significant disparities were observed between the two techniques in terms of failed intubation, initial successful intubation attempt, or sore throat/hoarseness. With regard to patient-reported satisfaction, a pooled analysis was precluded due to the variability in evaluation methods employed across the trials to assess this outcome. Lastly, trial sequential analysis (TSA) conducted for intubation time (primary outcome) affirmed the conclusiveness of this evidence; TSA performed for secondary outcomes failed to yield conclusive evidence, indicating the necessity for further trials. Conclusions: Videolaryngoscopy for awake tracheal intubation diminishes intubation time and the risk of experiencing a saturation below 90% compared to fiberoptic bronchoscopy. [ABSTRACT FROM AUTHOR]

Airway management in a patient with a displaced mandibular fracture remains a challenging task for anaesthesiologists due to distorted anatomy, managing shared airways and choosing appropriate airway management techniques preoperatively. This case report emphasises the importance of using the hybrid technique with a fibreoptic bronchoscope (FOB) and video laryngoscope (VL) for nasal intubation in such a challenging situation. [ABSTRACT FROM AUTHOR]

Pleural tumours represent a small yet significant subset of thoracic malignancies. Solitary Fibrous Tumours of the Pleura (SFTPs) are typically benign and account for 5% of all pleural tumours. Authors report a case of SFTPs excision with a postoperative diagnosis of Doege Potter Syndrome (DPS) in a 63-year-old male patient who was referred with complaints of chronic productive cough and breathlessness. Upon clinical and radiological evaluation, he was diagnosed with SFTPs. The patient experienced preoperative and intraoperative hypoglycaemic episodes, which were diagnosed as DPS during postoperative evaluation. This syndrome is a paraneoplastic condition associated with the secretion of Insulin-like growth factor-2 (IGF-II), observed in less than 5% of patients with SFTPs, with hypoglycaemia being a major symptom. Awake intubation and other procedures were performed with the patient in a propped-up position as he was unable to lie supine, which caused dyspnoea. [ABSTRACT FROM AUTHOR]

Background: Due to a lack of randomised controlled trials and guidelines, and only case reports being available in the literature, there is no consensus on how to approach anaesthetic management in patients with giant intraabdominal tumours. Methods: This study aimed to evaluate the literature and explore the current status of evidence, by undertaking an observational research design with a descriptive account of characteristics observed in a case series referring to patients with giant intraabdominal tumours who underwent anaesthesia. Results: Twenty patients diagnosed with giant intraabdominal tumours were included in the study, most of them women, with the overall pathology being ovarian-related and sarcomas. Most of the patients were unable to lie supine and assumed a lateral decubitus position. Pulmonary function tests, chest X-rays, and thoracoabdominal CT were the most often performed preoperative evaluation methods, with the overall findings that there was no atelectasis or pleural effusion present, but there was bilateral diaphragm elevation. The removal of the intraabdominal tumour was performed under general anaesthesia in all cases. Awake fiberoptic intubation or awake videolaryngoscopy was performed in five cases, while the rest were performed with general anaesthesia with rapid sequence induction. Only one patient was ventilated with pressure support ventilation while maintaining spontaneous ventilation, while the rest were ventilated with controlled ventilation. Hypoxemia was the most reported respiratory complication during surgery. In more than 50% of cases, there was hypotension present during surgery, especially after the induction of anaesthesia and after tumour removal, which required vasopressor support. Most cases involved blood loss with subsequent transfusion requirements. The removal of the tumor requires prolonged surgical and anaesthesia times. Fluid drainage from cystic tumour ranged from 15.7 L to 107 L, with a fluid extraction rate of 0.5–2.5 L/min, and there was no re-expansion pulmonary oedema reported. Following surgery, all the patients required intensive care unit admission. One patient died during hospitalization. Conclusions: This study contributes to the creation of a certain standard of care when dealing with patients presenting with giant intraabdominal tumour. More research is needed to define the proper way to administer anaesthesia and create practice guidelines. [ABSTRACT FROM AUTHOR]

Awake intubation is considered the standard of care for the management of the anticipated difficult airway. For its pharmacological properties, remifentanil is ideal for managing difficult endotracheal insertions. This process is augmented by the use of transtracheal injection of lidocaine as it disperses evenly around the area and facilitates the action of remifentanil further. A 48-year-old male patient, weight 200 kg, 184cm tall (BMI>40) came into the emergency room for severe hypercapnic hypoxic respiratory failure. Awake fiberoptic intubation was the option to secure the airway. Successful airway management is critical to the practice of emergency medicine. All anesthesiologists should be familiar with the airway management of obese patients.

Maxillofacial injury may cause difficulty during airway assessment and management in the emergency setting. Alternative intubation positions and techniques should be considered to ensure patient safety. A 37-year-old male patient arrived at the emergency department with a degloving maxillofacial injury after a high-impact motor vehicle accident. Active bleeding from his wounds prevented him from lying supine and raised concerns of aspiration, requiring immediate securing of the airway. Since the patient was alert and cooperative, awake face-to-face intubation in the upright position was performed. Intubation was successful on the first attempt without any complications using a video laryngoscope with topical anesthesia sprayed intraorally. Awake intubation in the face-to-face upright position can be successful in a cooperative patient with severe maxillofacial trauma.

Maxillofacial injury may cause difficulty during airway assessment and management in the emergency setting. Alternative intubation positions and techniques should be considered to ensure patient safety. A 37-year-old male patient arrived at the emergency department with a degloving maxillofacial injury after a high-impact motor vehicle accident. Active bleeding from his wounds prevented him from lying supine and raised concerns of aspiration, requiring immediate securing of the airway. Since the patient was alert and cooperative, awake face-to-face intubation in the upright position was performed. Intubation was successful on the first attempt without any complications using a video laryngoscope with topical anesthesia sprayed intraorally. Awake intubation in the face-to-face upright position can be successful in a cooperative patient with severe maxillofacial trauma. [ABSTRACT FROM AUTHOR]

Awake flexible bronchoscopic intubation is the commonly preferred technique of airway management in patients with known or predicted difficult airway. This is performed either by oral or nasal route and the technique involves complex psychomotor skill, requiring a trained or experienced operator. In contrast, supraglottic airway guided bronchoscopic intubation is a low-skill fiberoptic intubation technique with high success even among novices. The successful use of LMA BlockBuster® has been described for awake flexible bronchosopic intubation in a patient with fixed cervical spine and history of failed intubation. [ABSTRACT FROM AUTHOR]

Awake fibreoptic intubation has been considered a gold standard in the management of the difficult airway. However, failure may cause critical situations. The aim of this study was to investigate the incidence and causes of failed awake fibreoptic intubation at a tertiary care hospital. The study was conducted at St. Olav University Hospital in Trondheim, Norway. Problems occurring during anaesthesia are routinely recorded in the electronic anaesthesia information system (Picis Clinical Solutions Inc.), including difficult intubations. We applied text search on all anaesthesia records between 2011 and 2021 and identified 833 awake fibreoptic intubations. The anaesthesia records were examined to identify failed awake fibreoptic intubations, the cause of failure and how the airway ultimately was secured. Among 233,938 patients who received anaesthesia, 90,397 received tracheal intubation and 833 received awake fibreoptic intubation. Twenty‐nine of the procedures failed. In nine patients the failure caused loss of airway control with desaturation and hypoventilation. The major causes of failure were dislodged tube after induction of general anaesthesia (n = 8), patient distress (n = 5), tube not able to pass (n = 5), and airway bleeding (n = 3). The situations were primarily solved using direct laryngoscopy, with or without bougie, or with video laryngoscopy. Tracheostomy was performed in four patients. Awake fibreoptic intubation failed in 3.5% of patients, most often due to dislocation, problems passing the tracheal tube, or patient discomfort. The failure rate was higher than in previous studies. [ABSTRACT FROM AUTHOR]

Summary: Videolaryngoscopy is a suitable alternative to flexible bronchoscopy to facilitate awake tracheal intubation. The relative effectiveness of these techniques in clinical practice is unknown. We compared flexible nasal bronchoscopy with Airtraq® videolaryngoscopy in patients with an anticipated difficult airway scheduled for awake tracheal intubation. Patients were allocated randomly to flexible nasal bronchoscopy or videolaryngoscopy. All procedures were performed with upper airway regional anaesthesia blockade and a target‐controlled intravenous infusion of remifentanil. The success rate with the allocated technique was the primary outcome. A non‐inferiority analysis with a predefined limit of 8% was planned. Seventy‐eight patients were recruited, allocated randomly and analysed. The rate of successful intubation was 97% and 82% in the flexible bronchoscopy and videolaryngoscopy groups, respectively, p = 0.032. The median (IQR [range]) time to tracheal intubation was shorter with the Airtraq, 163 (105–332 [40–1004]) vs. 217 (180–364 [120–780]) s, p = 0.030. There were no significant differences for complications found between the groups. The median visual analogue scale for ease of intubation was 8 (7–9 [0–10]) for Airtraq vs. 8 (7–9 [0–10]) for flexible bronchoscopy, p = 0.710. The median visual analogue scale for patient comfort for Airtraq was 8 (6–9 [2–10]) vs. 8 (7–9 [3–10]) for flexible bronchoscopy, p = 0.370. The Airtraq videolaryngoscope is not non‐inferior to flexible bronchoscopy for awake tracheal intubation in a clinical setting when awake tracheal intubation is indicted. It may be a suitable alternative when judged on a case‐by‐case basis. [ABSTRACT FROM AUTHOR]

A flexible fibreoptic scope can be used to facilitate tracheal intubation in both awake and asleep patients, in those with limited or absent mouth opening and complex anatomy. It may be used as a first choice for airway management or as a rescue technique. Despite its potential limitations, e.g. in situations with significant blood or secretions in the airway, fibreoptic intubation remains an invaluable core skill for every anaesthetist. Awake tracheal intubation must be considered in the presence of predictors of difficult airway management. [ABSTRACT FROM AUTHOR]

Background This work was conducted to examine the efficiency of using C-MAC video stylet (VS) in awake intubation by comparing it to the standard method using fibreoptic bronchoscope (FOB).Patients and methodology Eighty patients were included in this study and divided into two groups according to the device used for awake intubation: VS group and FOB group.Results The intubation time ranged between 25 and 245 s with median of 45.5 s in VS group, while in the FOB group, it ranged between 36 and 279 s with median of 80 s with P value < 0.001. Successful intubation was done in 36 patients (90%) on the first attempt in VS group versus 29 patients in the FOB group (72.5%) with P value 0.04. As regard SpO2, insignificant difference was found all through measurement times. Heart rate and mean arterial blood pressure showed significant increase in FBO group more than in CMAC-VS group at 1 and 5 min after intubation with P value < 0.001.Conclusion Using the C-MAC VS in awake intubation proved to be easier and more successful than using the FOB.

Background: In case of distorted airway anatomy, awake intubation with a flexible bronchoscope can be extremely difficult or even impossible. To facilitate this demanding procedure, an infrared flashing light source can be placed on the patient's neck superficial to the cricothyroid membrane. The light travels through the skin and tissue to the trachea, from where it can be registered by the advancing bronchoscope in the pharynx and seen as flashing white light on the monitor. We hypothesised that the application of this technique would allow more proximal and easier identification of the correct pathway to the trachea in patients with severe airway pathology. Methods: As part of awake intubation, patients underwent insertion of a flexible video bronchoscope via the mouth into the trachea. The procedure was performed twice, in random order in each patient, with and without the aid of the transcutaneous flashing infrared light. All insertions were video recorded to determine at which anatomical landmark within the airway the correct pathway was identified. The videos are accessible via this link: https://airwaymanagement.dk/infrared%5fcomparative. The predefined landmarks were in successive order: oral cavity, oro‐pharynx, tip of epiglottis, arytenoid cartilages, false cords, vocal cords and trachea, as well as the spaces between them. Results: Twenty‐two patients had a total of 44 awake insertions with the flexible bronchoscope. The median anatomical level, at which correct identification of the trachea was obtained on the monitor, was, past the epiglottis, with the conventional technique, and at the level of the oropharynx, when using the infrared flashing light (p =.005). The time until the flashing light or the vocal cords were seen was 21 (22) S, mean (SD), and 48 (62) S, during the insertion with and without infrared flashing light activated, respectively (p =.005). Endoscopists rated it easier (p =.001) to recognise the entrance to the trachea in the infrared‐group. Conclusion: During awake intubation of patients with airway pathology, the application of trans‐cricothyroid infrared flashing light to guide the insertion of a flexible bronchoscope significantly facilitated the recognition of the pathway into the trachea and the correct advancement of the flexible endoscope. Registration of Clinical Trial: NCT03930550. [ABSTRACT FROM AUTHOR]

Abstract Background Anesthetic management of thoracic aortic aneurysms (TAAs) is sometimes difficult due to fatal complications, including hypovolemic shock secondary to aneurysm rupture. We report the successful management of an impending rupture of a TAA with associated esophageal stenosis and compression of the pulmonary artery and left bronchi. Case presentation An 83-year-old woman, diagnosed with an impending rupture of the ascending TAA, was scheduled to undergo emergency total aortic arch replacement. Computed tomography showed esophageal stenosis with significant amounts of food residues in the thoracic esophagus and compression of the pulmonary artery and bronchi. We performed awake intubation and superior laryngeal nerve block with light sedation to prevent aspiration and aneurysmal rupture, respectively. General anesthesia was induced immediately after the intubation. No intraoperative complications occurred. Conclusions Performing awake intubation with a superior laryngeal nerve block and sedation may prevent aspiration of food residues and hemodynamic changes that may lead to rupture.

Airway management in a case of parapharyngeal abscess is challenging as there can be airway obstruction during anaesthetic induction. We describe airway management in 13-yr-old child with parapharyngeal abscess scheduled for incision and drainage. Informed consent was taken for publishing this case report. [ABSTRACT FROM AUTHOR]

This work was conducted to examine the efficiency of using C-MAC video stylet (VS) in awake intubation by comparing it to the standard method using fibreoptic bronchoscope (FOB). Eighty patients were included in this study and divided into two groups according to the device used for awake intubation: VS group and FOB group. The intubation time ranged between 25 and 245 s with median of 45.5 s in VS group, while in the FOB group, it ranged between 36 and 279 s with median of 80 s with P value < 0.001. Successful intubation was done in 36 patients (90%) on the first attempt in VS group versus 29 patients in the FOB group (72.5%) with P value 0.04. As regard SpO2, insignificant difference was found all through measurement times. Heart rate and mean arterial blood pressure showed significant increase in FBO group more than in CMAC-VS group at 1 and 5 min after intubation with P value < 0.001. Using the C-MAC VS in awake intubation proved to be easier and more successful than using the FOB. [ABSTRACT FROM AUTHOR]

Ririko Nagabuchi,1 Hikari Minami,1 Makoto Sakikawa,2 Yoshiko Onodera,1 Megumi Kanao-Kanda,1 Hirotsugu Kanda1 1Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan; 2Department of Dentistry and Oral Surgery, Rinseikai Yoshida Hospital, Nayoro, JapanCorrespondence: Hirotsugu KandaDepartment of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan, Tel +81-166-68-2583, Fax +81-166-68-2589, Email h.kanda0629@nifty.comPurpose: Intubation and ventilation cannot be performed in cases of parapharyngeal space tumors as the enlargement of the upper airway leads to the obstruction and hindrance of the intubation procedure. However, there is limited literature on anesthetic management, including the airway, in this disease. Herein, we report a successful case of awake intubation in a patient with parapharyngeal space tumor.Case Presentation: A 64-year-old man with a history of giant parapharyngeal space tumor was scheduled for bilateral endoscopic sinus surgery and nasal septoplasty. We performed awake intubation using the McGrath® video laryngoscope, which resulted in excellent laryngeal deployment and a smooth procedure.Conclusion: We report the anesthetic management of a giant parapharyngeal space tumor with the potential for difficult airway management to maintain spontaneous breathing. Awake intubation was useful in maintaining ventilation and intubation in this case. The preparation of a cricothyroid puncture is needed in cases of intubation failure.Keywords: parapharyngeal space tumor, awake intubation, video laryngoscope

There is a search for an ideal agent to facilitate awake fiberoptic intubation (AFOI). Dexmedetomidine is a selective α2 agonist which can be administered through intravenous, intramuscular, buccal, intranasal & inhalational routes. It provides good intubation conditions without oxygen desaturation but may cause hypotension and bradycardia when administered intravenously. Hence, alternative routes of administering dexmedetomidine which may improve its safety profile are worth exploring. In this randomised, controlled, double-blind trial, 46 ASA I/II adult participants scheduled for elective ENT surgery were randomly allocated to Group ND (Nebulised Dexmedetomidine) (n = 23) to receive nebulisation with dexmedetomidine 1μg.kg−1 and Group ID (Intravenous Dexmedetomidine) (n = 23) to receive intravenous dexmedetomidine 1μg.kg−1 before AFOI. All the patients received injection midazolam 1 mg i.v. as premedication before anaesthesia was initiated. The primary outcome was the cough score. The secondary outcomes were the RSS, SAYGO boluses, post-intubation score, hemodynamic parameters, recall of the procedure, patient satisfaction score and any side effects. The cough score was significantly lower in nebulized group (2.43 ± 0.992 vs 3.52 ± 1.082) with p = 0.001. RSS(3.30 ± 0.926 vs 4.22 ± 1.126; p = 0.004), number of SAYGO boluses required (2.74 ± 0.864 vs 3.57 ± 1.161; p = 0.009) & the post intubation score (1.48 ± 0.593 vs 2.17 ± 0.778; p = 0.001) were also significantly lower in nebulized group. Nebulisation with dexmedetomidine results in desirable degree of sedation and better tolerance of the procedure with adequate attenuation of the haemodynamic responses to intubation. • There is a search for an ideal agent to facilitate awake fiberoptic intubation (AFOI). • I.V. Dexmedetomidine provides good intubation conditions without oxygen desaturation but may cause hypotension and bradycardia. • Nebulised dexmedetomidine provided desirable sedation and better tolerance of the procedure without haemodynamic side effects. [ABSTRACT FROM AUTHOR]

Background: Anesthetic management of thoracic aortic aneurysms (TAAs) is sometimes difficult due to fatal complications, including hypovolemic shock secondary to aneurysm rupture. We report the successful management of an impending rupture of a TAA with associated esophageal stenosis and compression of the pulmonary artery and left bronchi. Case presentation: An 83-year-old woman, diagnosed with an impending rupture of the ascending TAA, was scheduled to undergo emergency total aortic arch replacement. Computed tomography showed esophageal stenosis with significant amounts of food residues in the thoracic esophagus and compression of the pulmonary artery and bronchi. We performed awake intubation and superior laryngeal nerve block with light sedation to prevent aspiration and aneurysmal rupture, respectively. General anesthesia was induced immediately after the intubation. No intraoperative complications occurred. Conclusions: Performing awake intubation with a superior laryngeal nerve block and sedation may prevent aspiration of food residues and hemodynamic changes that may lead to rupture. [ABSTRACT FROM AUTHOR]

Latar Belakang: Insiden tracheoesophageal fistula (TEF) dan esophageal atresia (EA) berkisar antara 1:3000 dan 1:4500 kelahiran. Antara 20% sampai 50% bayi dengan TEF/EA memiliki defek kongenital lainnya yang biasa disebut VACTERL (vertebral, anal, cardiac, tracheoesophageal, renal, limb). Kasus: Bayi usia 30 hari berat badan 2600 gram dengan diagnosis TEF tipe C dengan komplikasi pneumonia neonatal dan penyakit jantung bawaan ASD sinus venosus besar dan PDA sedang direncanakan tindakan thorakotomi ligasi fistel. Pasien sudah dilakukan gastrostomi dan esofagostomi sebelum tindakan ligasi. Pasien dilakukan manajemen anestesi dengan general anestesi intubasi dengan kontrol ventilasi. Selama operasi terjadi beberapa kali desaturasi akibat retraksi paru yang dimanajemen dengan ventilasi manual dengan pemberian PEEP dan pengurangan retraksi oleh operator. Dua hari post operasi pasien dilakukan ekstubasi dan diganti dengan CPAP. Kesimpulan: Manajemen anestesi dengan TEF/EA memerlukan evaluasi dan perencanaan mulai preoperatif, intraoperatif, dan postoperatif. Evaluasi preoperatif berupa investigasi VACTERL, masalah kardiak dan respirasi berkaitan perencanaan manajemen anestesi yang akan dilakukan. Manajemen intraoperatif termasuk teknik intubasi, pemilihan teknik awake atau apnea bergantung kondisi dan komorbid dari pasien. Manajemen postoperatif berupa perawatan ventilator, kontrol nyeri optimal serta pengawasan kardiorespirasi.

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Background: Retrograde intubation is one of the well-described and alternative methods of difficult airway management. It requires effective sedation and patient preparation. Study was done to evaluate intubating conditions during retrograde guided intubation with two different doses of dexmedetomidine. Methods: This prospective randomized double blind parallel group trial was planned on 60 patients with difficult airway. Patients were divided in two groups to receive either dexmedetomidine 1.0 μg/kg (Group A) or dexmedetomidine 1.5 μg/kg (Group B) by intravenous (IV) route. The Modified Observer Assessment Awareness and Sedation (OAA/S) was measured as primary outcome and ease of intubation, facial grimace score, cough severity, hemodynamic response, patient recall and discomfort were assessed as secondary outcome during awake retrograde intubation. Results: Groups were comparable in terms of demographic and baseline parameters. OAA/S (P = 0.001), cough severity (P 0.05) between the two groups. Conclusion: Retrograde intubation can be easily learned and performed with minimal complications. Dexmedetomidine in a dose of 1.5 μg/kg IV is optimum and safe for retrograde intubation with clinically manageable side effects.

Introduction: In this retrospective study a review of 40 cases of airway management for newborns with tracheoesophageal fistula (TEF) /esophageal atresia repair is presented. Almost all cases had associated cardiac anomalies. Materials and Methods: Selected management was awake intubation with flow of oxygen via Mapelson F. Sedated awake intubation was performed using Atropine 0.02 mg/kg and Fentanyl1 µg/kg, and then occlusion of the fistula with ligation. Result: In patients with small TEF, there was no problem in intubation and ventilation. Anesthesia management and post operative NICU care was performed for 26 cases with no problem, but in 14 cases there was difficulty for anesthesia management and NICU care. Conclusion: We had no complication with performing the awake intubation technique.

Abstract By combining video laryngoscopy and fiberoptic bronchoscopy, awake intubation can be performed more safely.

Purpose: Intubation and ventilation cannot be performed in cases of parapharyngeal space tumors as the enlargement of the upper airway leads to the obstruction and hindrance of the intubation procedure. However, there is limited literature on anesthetic management, including the airway, in this disease. Herein, we report a successful case of awake intubation in a patient with parapharyngeal space tumor. Case Presentation: A 64-year-old man with a history of giant parapharyngeal space tumor was scheduled for bilateral endoscopic sinus surgery and nasal septoplasty. We performed awake intubation using the McGrath® video laryngoscope, which resulted in excellent laryngeal deployment and a smooth procedure. Conclusion: We report the anesthetic management of a giant parapharyngeal space tumor with the potential for difficult airway management to maintain spontaneous breathing. Awake intubation was useful in maintaining ventilation and intubation in this case. The preparation of a cricothyroid puncture is needed in cases of intubation failure. [ABSTRACT FROM AUTHOR]

Airway management of patients with difficult airways is a challenge to the anesthesiologists and awake tracheal intubation is the recommended strategy. Successful fiberoptic‐guided tracheal intubation under precise anesthesia and topicalization with spontaneous respiration preservation was achieved in an uncooperative patient with severe postburn mentosternal contracture scheduled for release of contracture. [ABSTRACT FROM AUTHOR]

Abstract Airway management of patients with difficult airways is a challenge to the anesthesiologists and awake tracheal intubation is the recommended strategy. Successful fiberoptic‐guided tracheal intubation under precise anesthesia and topicalization with spontaneous respiration preservation was achieved in an uncooperative patient with severe postburn mentosternal contracture scheduled for release of contracture.

Abstract Background The anesthesia of patients with large mediastinal mass is at high-risk. Avoidance of general anesthesia in these patients is the safest option, if this is unavoidable, maintenance of spontaneous ventilation is the next safest technique. In these types of patients, it is not applicable to use double-lumen tube (DLT) to achieve one-lung ventilation (OLV) because the DLT has a larger diameter and is more rigid than single-lumen tube (SLT), so the mass may rupture and bleed during intubation. Even using a bronchial blocker, a small size of SLT is required for once the trachea collapses the SLT can pass through the narrowest part of trachea. However, it is difficult to control the fiberoptic bronchoscopy (FOB) and the bronchial blocker simultaneously within the lumen of a small size SLT with traditional intubation methods. Case presentation The current study presented a 66 years old female patient with a large mediastinal mass that presented with difficulty breathing when lying flat. In this case, we combined use of dexmedetomidine and remifentanil to preserve the patient’s spontaneous ventilation during intubation and achieved one-lung ventilation with extraluminal use of Uniblocker. Conclusions Extraluminal use of Uniblocker and maintenance of spontaneous ventilation during intubation may be an alternative to traditional methods of lung isolation in such patients with a large mediastinal mass.

Fibreoptic bronchoscopy-guided intubation (FOBI) is ideal in establishing the airway in patients with anticipated difficult airway before the induction of general anaesthesia. At times, patient factors lead to the need for FOBI in unconventional positions. We encountered a patient with postburn contracture with fixed flexion deformity of the neck who was unable to lie supine. Awake FOBI in sitting position turned out to be the ideal position for our patient. [ABSTRACT FROM AUTHOR]

Awake intubation is indicated in difficult airways if attempts at securing the airway after induction of general anesthesia may lead to harm due to potential difficulties or failure in those attempts. Conventional awake flexible bronchoscopic intubation is performed via the nasal, or less commonly, oral route. Awake oral flexible bronchoscopic intubation (FBI) via a supraglottic airway device (SAD) is a less common technique; we refer to this as ‘supraglottic airway guided’ FBI (SAGFBI). We describe ten cases with anticipated difficult airways in which awake SAGFBI was performed. After sedation and adequate airway topicalization, an Ambu AuragainTM SAD was inserted. A flexible bronchoscope, preloaded with a tracheal tube, was then inserted through the SAD. Finally, the tracheal tube was railroaded over the bronchoscope, through the SAD and into the trachea. The bronchoscope and the SAD were carefully removed, whilst keeping the tracheal tube in-situ. The technique was successful and well tolerated by all patients, and associated complications were rare. It also offered the advantages of performing an ‘awake test insertion’ of the SAD, an ‘awake look’ at the periglottic region, and an ‘awake test ventilation.’ In certain patients, awake SAGFBI offers advantages over conventional awake FBI or awake videolaryngoscopy. More research is required to evaluate its success and failure rates, and identify associated complications. Its place in difficult airway algorithms may then be further established.

Anatomical disorders of the head and neck pose a serious challenge to an anesthesiologist in terms of difficult intubation. Securing airway requires a detailed preanesthesia evaluation to assess any issues associated with the disease, especially concerning the airway. This is the case of a 46-year-old male with congenital bilateral torticollis posted for elective functional endoscopic sinus surgery. A detailed preanesthetic checkup was done and was anticipated a difficult airway situation, hence planned for an awake intubation. We performed a successful awake fiber-optic intubation. Excessive muscular atrophy and fibrosis characterize congenital bilateral torticollis, resulting in sternocleidomastoid tension and limited cervical motion. During intubation, asymmetry in the face caused a mismatch between the facial and cervical midlines, making sniffing difficult. Successful anesthetic management in a case of congenital bilateral torticollis requires thorough knowledge about the anatomical changes and also the expertise in fiber-optic bronchoscopy.

Background: Awake fiber-optic bronchoscopy-guided intubation is the method of choice in difficult airway which requires effective airway anesthesia to ensure patient comfort and acceptance. Aims: This study was conducted to assess the quality of airway anesthesia, patient comfort during intubation, and postoperative satisfaction of patients. Settings: Patients posted for surgeries under general anesthesia with Mallampati Grade I and II in a medical college. Patients were followed in the operation theater and postoperative ward. Study Design: This was a prospective randomized single-blind study. Materials and Methods: Group D received intravenous (i.v.) dexmedetomidine 1 μg.kg−1 i.v. over 10 min and 3 ml of 4% lignocaine spray as you go (SAYGo). Group F received i.v. fentanyl 2 μg.kg−1 over 10 min and transtracheal injection 3 ml of 4% lignocaine. Parameters assessed were endoscopic time, intubating condition, vocal cord position, cough severity, comfort during intubation, postoperative patient satisfaction, and any adverse effects such as sore throat, hoarseness, unpleasant memories, and hemodynamic response during intubation. Statistical Analysis: Independent Student's t-test, Mann–Whitney, Chi-squared test, or Fisher's exact test were used. P ≤ 0.05 was considered statistically significant. Results: Intubating conditions, vocal cord position, cough severity, comfort during intubation, and postoperative patient satisfaction were statistically significant (P ≤ 0.05) in favor of Group D though endoscopic time was longer. Conclusion: IV dexmedetomidine with SAYGo is effective than IV fentanyl with transtracheal block for awake fiber-optic videoscopic intubation in terms of intubating conditions, vocal cord position, cough severity, comfort during intubation, and postoperative satisfaction of patients with significant attenuation of postintubation hemodynamic response and better preservation of respiration though endoscopic time is more. [ABSTRACT FROM AUTHOR]

Jia Jiang,1 Da-Xu Ma,1 Bo Li,2 An-Shi Wu,1 Fu-Shan Xue31Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China; 2Beijing Hospital of Traditional Chinese Medicine, Affiliated to Capital Medical University, Beijing Institute of Traditional Chinese Medicine, Beijing 100010, China; 3Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China Background: Awake intubation with videolaryngoscopy (VL) is a novel method that is drawing more and more attention as an alternative to awake intubation with fiberoptic bronchoscope (FOB). This meta-analysis is designed to determine the performance of VL compared to the FOB for awake intubation.Methods: The Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web of science were searched from database inception until October 30, 2017. Randomized controlled trials comparing VL and FOB for awake intubation were selected. The primary outcome was the overall success rate. Rev-Man 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible study. The GRADE system was used to assess the quality of evidence for all outcomes.Results: Six studies (446 patients) were included in the review for data extraction. Pooled analysis did not show any difference in the overall success rate by using VL and FOB (relative risk [RR], 1.00; P=0.99; high-quality evidence). There was no heterogeneity among studies (I2=0). Subgroup analyses showed no differences between two groups through nasal (RR, 1.00; P=1.00; high-quality evidence) and oral intubations (RR, 1.00; P=0.98; high-quality evidence). The intubation time was shorter by using VL than by using FOB (mean difference, -40.4 seconds; P0.05).Conclusion: For awake intubation, VL with a shorter intubation time is as effective and safe as FOB. VL may be a useful alternative to FOB.Keywords: airway management, awake intubation, videolaryngoscopy, fiberoptic bronchoscopy, randomized controlled clinical trials, outcomes

Flexible fibre-optic intubation offers options of airway control in awake and asleep patients, in cases with limited or absent mouth opening and complex anatomy. It may be used as a first choice or a rescue technique. Despite its limitations, e.g. in situations with significant airway blood or secretions, and airway obstruction, it is a valuable core skill for every anaesthetist. [ABSTRACT FROM AUTHOR]

Direct laryngoscopy with the insertion of a tracheal probe through the vocal cords is a routine procedure for general anesthesia. However, there may be certain anatomical conditions, pathologies of airways, polytraumas, morbid obesity, where viewing the glottis by direct laryngoscopy may be difficult or impossible, a case in which the anesthesiologist recognizes it and defines it as a difficult airway. The recommendation for awake intubation addresses to the cases of difficult airways to which anesthesia and/or muscle relaxation may lead to the case of "cannot ventilate, cannot intubate". The method described is safe and efficient and can be advised for the cases in which there are serious doubts regarding the possibility of maintaining the airways open during the inducing of anesthesia or for the cases in which the intubation failed during prior anesthesia. The intubation of an awake patient is rarely associated with severe desaturation episodes and is usually well tolerated by motivated patients. Consequently, the neuroanatomy of the upper airways is presented in this article with the description of several techniques that can be used for the anesthesia of the airways for intubation. These techniques include local anesthesia by direct application on the respiratory mucosa as well as the description of some types of nerve blocks. [ABSTRACT FROM AUTHOR]

Retrograde intubation is one of the well-described and alternative methods of difficult airway management. It requires effective sedation and patient preparation. Study was done to evaluate intubating conditions during retrograde guided intubation with two different doses of dexmedetomidine. This prospective randomized double blind parallel group trial was planned on 60 patients with difficult airway. Patients were divided in two groups to receive either dexmedetomidine 1.0 μg/kg (Group A) or dexmedetomidine 1.5 μg/kg (Group B) by intravenous (IV) route. The Modified Observer Assessment Awareness and Sedation (OAA/S) was measured as primary outcome and ease of intubation, facial grimace score, cough severity, hemodynamic response, patient recall and discomfort were assessed as secondary outcome during awake retrograde intubation. Groups were comparable in terms of demographic and baseline parameters. OAA/S (P = 0.001), cough severity (P < 0.001), facial grimace score (P < 0.001), grading of discomfort during procedure (P < 0.001) and recall of procedure scale (P = 0.038) were found significantly better/lower in Group B as compared to Group A. Hemodynamic parameters were better in Group B and showed significant difference during the retrograde intubation. However, ease of intubation scale, intubating time and complications were not significantly different (P > 0.05) between the two groups. Retrograde intubation can be easily learned and performed with minimal complications. Dexmedetomidine in a dose of 1.5 μg/kg IV is optimum and safe for retrograde intubation with clinically manageable side effects. [ABSTRACT FROM AUTHOR]

We report successful awake intubation in a morbidly obese patient (body mass index of 61.2) using an epidural catheter inserted through the external forceps channel of the fiberscope for delivery of local anesthetic. Direct application of local anesthetic to the pharyngolaryngeal area and proximal tracheal, through the use of a relatively firm epidural catheter. We conclude that awake intubation can be achieved by this method which spares the subsequent use of any sedative drugs. [ABSTRACT FROM AUTHOR]

Objective To study the effect of surface anesthesia guided by fiberoptic bronchoscope on awake orotracheal fiberoptic intubation. Methods Sixty patients with elective laryngeal surgery under general anesthesia and with tracheal intubation difficulties,were randomly divided into two groups:group A received pharyngeal surface anesthesia and surface anesthesia guided by fiberoptic bronchoscope,and group B received pharyngeal surface anesthesia and airway surface anesthesia by cricothyroid membrane puncture.The patient was then intubated through the mouth guided by fiberoptic bronchoscope. Intubation time,cough score of patients during surface anesthesia,nausea,cough score of patients during intubation,comfort score during intubation,and tolerance score and patient comfort score after intubation were recorded.Oxygen saturation(SpO2),average arterial pressure (MAP) and heart rate (HR) were recorded after enter the operating room (T0),after surface anesthesia (T1),after tracheal tube entry into glottis (T2),and after intubation and before injection of general anesthesia (T3). Results The cough score of patients during local anesthesia, nausea score during intubation, cough score of patients during intubation,comfort score during intubation, and tolerance score after intubation in group A were all lower than those in group B (P<0.05).At T0 and T1,there was no significant difference in HR and MAP between the two groups.At T2 and T3,HR and MAP in group A were lower than those in group B (P<0.05).There was no significant difference in SpO2 between the two groups at all time points. Conclusion Surface anesthesia guided by fiberoptic bronchoscope can provide better intubation conditions and higher patient satisfaction for patients with laryngeal cancer,compared with traditional endotracheal surface anesthesia by cricothyroid membrane puncture. [ABSTRACT FROM AUTHOR]

Background: Patients with potential difficult mask ventilation (DV) and difficult intubation (DI) are often managed with awake intubation, which can be stressful for patients and anesthesiologists. This prospective randomized study evaluated a new approach, fast difficult airway evaluation (FDAE). We hypothesized that the FDAE approach would reduce the need for awake intubation. Methods: After obtaining informed consent, 302 patients with potential DV/DI undergoing elective surgeries were randomly assigned to the FDAE group (Group E) and the control group (Group C). In Group E, patients were gradually sedated, and adequacy of manual mask ventilation during spontaneous breathing was assessed at various sedation levels. Awake intubation was applied in those with inadequate mask ventilation. In Group C, DI was evaluated under local anesthesia. However, the care team could intubate under general anesthesia if the vocal cords were visible. The primary outcome was the rate of awake intubations in both groups and the induction efficiency assessed by the induction time. The secondary outcome was the incidence of serious complications. Results: The rate of awake intubation was significantly lower in Group E than that in Group C (5.81% vs. 36.05%, χ2 = 42.3, P < 0.001). The induction time was much shorter in Group E than in Group C (11.85 ± 4.82 min vs. 18.71 ± 7.85 min, t = 5.39, P < 0.001). There was no significant difference in the incidence of intubation related complications between the two groups. Patients in Group E had a much lower incidence of recall (9.68% vs. 44.90%, χ2 = 47.68, P < 0.001) of the induction process and higher satisfaction levels than patients in Group C (t = 15.36, P < 0.001). Conclusions: The FDAE significantly reduces the need for awake intubation and improves the efficiency of the intubation process without comprising safety in patients with potential difficult mask ventilation and DI. Trial Registration: No. ChiCTR-TRC-11001418; http://www.gctr.org/cn/proj/show.aspx?proj=1562.

Airway management of patients undergoing thyroidectomy for Retrosternal Goitre (RSG) poses a unique challenge. Associated comorbidities, manipulation of the airway by the surgeons, airway compromise during induction, intubation, intraoperative and postoperative period can contribute to adverse events. We describe anaesthetic management of a patient with long standing goitre for 61 years with retrosternal extension with tracheal narrowing and compression for thyroidectomy. We secured the airway in an awake, spontaneously breathing patient under topical anaesthesia and sedation using direct laryngoscopy. Airway management of RSG is challenging at every phase of anaesthesia. Maintaining airway patency, vigilance and preparedness are keys to the success of intubation.