BACKGROUND: Fiberoptic-guided intubation is considered as \"gold standard\" of difficult airway management. Management of the airway in prone position in patients with severe trauma presenting with penetrating waist and hip injury poses a major challenge to the anesthesiologist.
METHODS: A man presented with severe multiple trauma and hemorrhagic shock as a result of an industrial accident with several deformed steel bars penetrating the left lower waist and hip. It was decided to schedule an exploratory laparotomy following extracting the deformed steel bars. Successful administration of awake fiberoptic nasotracheal intubation, performed in a prone position under airway blocks and appropriate sedation, allowed for the procedure. The exploratory laparotomy revealed damage to multiple organs, which were repaired sequentially during a 7-hour surgical operation. The patient\'s recovery was uneventful, and he was discharged from the hospital one month after the surgery.
CONCLUSIONS: Awake fiberoptic nasotracheal intubation, along with airway blocks and appropriate sedation, can be a viable option in patients with severe multiple trauma in the prone position.

Bronchogenic cysts (BCs) are a congenital anomaly, forming fluid-filled sacs in the bronchial tree during fetal development, and are relatively rare in adults. Patients with large BCs in the mediastinum presenting with severe tracheal compression pose a significant challenge to anesthesiologists. The confined and narrow space of the mediastinum exacerbates the compression effect on surrounding structures, leading to potential respiratory or cardiovascular collapse during anesthesia and postoperatively. Herein, we report the stepwise anesthetic management of a patient with a BC in the paratracheal region of superior mediastinum, causing near-complete tracheal compression, scheduled for right posterolateral thoracotomy and tumor excision. The patient presented with dyspnea, chest pain, cough, and severe tracheal compression necessitating meticulous airway management. Utilizing awake fiberoptic intubation with a single-lumen endotracheal tube and one-lung ventilation facilitated by an EZ bronchial blocker, we successfully secured the airway, provided ideal surgical conditions through lung deflation, and ensured perioperative safety. This case underscores the crucial role of comprehending the underlying pathophysiology, anticipating complications, and meticulously planning, preparing, and executing strategies for airway management and perioperative care in patients with mediastinal masses leading to significant tracheal compression.

Transoral robotic surgery (TORS) is a minimally invasive surgical technique that has recently gained popularity. This involves the use of a robotic system to access and operate on hard-to-reach areas of the body, such as the base of tongue and pharynx. General anesthesia is the technique of choice in TORS as this procedure poses unique challenges due to the patient\'s airway anatomy, the need for precise surgical movements, and the potential for postoperative complications. Awake fiberoptic intubation (AFOI) is the gold standard for an anticipated difficult airway. This case report describes the anesthetic management for a patient undergoing TORS for a tongue base mass.

A 56-year-old female patient with a history of breast cancer, anxiety, and depression developed rapid-onset cervical necrotising fasciitis following a fall at home where she sustained multiple rib fractures and lacerations. The case highlights the challenge of managing a rapidly progressing airway obstruction and the successful management of the patient\'s condition with awake fibreoptic intubation and subsequent surgical intervention.

Ameloblastomas are rare tumors that arises from the odontogenic epithelium. Although benign and slow growing, an extensive lesion may cause airway obstruction, making bag-mask ventilation and intubation a significant challenge. Here, we present a 54-year-old male in respiratory distress with an 18x15x13 cm submandibular mass causing airway compromise. The tumor was extensive, occupying most of the oral cavity. Unable to perform direct laryngoscopy because of the tumor burden, we performed an awake nasal fiberoptic intubation to secure the airway. Successful intubation was achieved as well as subsequently tracheostomy. We subsequently provide a discussion on associated challenges and management options for patients with ameloblastomas.

UNASSIGNED: Ludwig\'s angina is a type of severe cellulitis that spreads rapidly and carries a significant risk of airway compromise. Previous complications with COVID-19 are poorly described within the literature.
UNASSIGNED: This case report describes the complication of COVID-19 infection with suspected Ludwig\'s angina 2 days after admission, resulting in awake fibroscopic endotracheal intubation. Emergent treatment and establishing a secure airway are paramount in these cases. We discuss the role of antibiotics and adjunct treatment in these cases of potential airway compromise.
UNASSIGNED: Limited data demonstrate simultaneous infection of COVID-19 with these types of submandibular soft tissue infections in the literature. Previous explorations into this subject are limited, as COVID-19 is a relatively new condition with its own treatment guidelines. We discuss specifically the role of corticosteroid use and surgical intervention in these cases. We wish to highlight awareness and treatment considerations for COVID-19 patients with superimposed Ludwig\'s angina.

BACKGROUND: Reports on perioperative anesthesia management in pediatric patients with difficult airways are scarce. In addition to relatively more difficulties in the technique of endotracheal intubation, the time for manipulation is restricted compared to adults. Securing the airways safely and avoiding the occurrence of hypoxemia in these patients are of significance.
METHODS: A 9-year-old boy with spastic cerebral palsy, severe malnutrition, thoracic scoliosis, thoracic and airway malformation, laryngomalacia, pneumonia, and epilepsy faced the risk of anesthesia during palliative surgery. After a thorough preoperative evaluation, a detailed scheme for anesthesia and a series of intubation tools were prepared by a team of anesthesiologists. Awake fiberoptic intubation is the widely accepted strategy for patients with anticipated difficult airways. Given the age and medical condition of the patient, we kept him sedated with spontaneous breathing during endotracheal intubation. The endotracheal intubation was completed on the second attempt after the failure of the first effort. Fortunately, the surgery was successful without postoperative complications.
CONCLUSIONS: Dealing with difficult airways in the pediatric population, proper sedation allows time to intubate without interrupting spontaneous breathing. The appropriate endotracheal intubation method based on the patient\'s unique characteristics is the key factor in successful management of these rare cases.

Difficult airway management is a challenge for anesthesiologists, requiring proper assessment, planning, and sometimes a multidisciplinary approach to establish a secure airway. Here we present a case where the patient had a large thyroid goiter with significant tracheal compression. Due to the large size of the thyroid mass and the location of tracheal narrowing, fiberoptic intubation appeared to be challenging, and a surgical airway was not a viable option to obtain a secure airway for a total thyroidectomy. This case report discusses awake fiberoptic intubation and intraoperative anesthetic management of a patient with known airway compression and explores the alternative method for obtaining a definitive airway through venovenous extracorporeal membrane oxygenation.

Epiglottitis is a bacterial infection of the upper respiratory tract that can be rapidly progressive and life-threatening. Though predominantly seen in unvaccinated children, there seems to be a shift with the incidence of adult cases rising following the Haemophilus Influenza B (HiB) vaccine. There are several reports of epiglottitis manifesting as an abscess, but few cases report on the formation of an emphysematous abscess. Additionally, little is known on the bacterial etiology of such infections. Here, we present a case of a patient found to have acute emphysematous epiglottis managed with fiberoptic intubation, drainage, and culture of the abscess. Laryngoscope, 133:2747-2750, 2023.

BACKGROUND: Patients with ankylosing spondylitis (AS) combined with severe cervical fusion deformity have difficult airways. Awake fiberoptic intubation is the standard treatment for such patients. Alleviating anxiety and discomfort during intubation while maintaining airway patency and adequate ventilation is a major challenge for anesthesiologists. Bronchial blockers (BBs) have significant advantages over double-lumen tubes in these patients requiring one-lung ventilation.
OBJECTIVE: To evaluate effective drugs and their optimal dosage for awake fiberoptic nasotracheal intubation in patients with AS and to assess the pulmonary isolation effect of one-lung ventilation with a BB.
METHODS: We studied 12 AS patients (11 men and one woman) with lung or esophageal cancer who underwent thoracotomy with a BB. Preoperative airway evaluation found that all patients had a difficult airway. All patients received an intramuscular injection of penehyclidine hydrochloride (0.01 mg/kg) before anesthesia. In the operating room, dexmedetomidine(0.5 μg/kg) was infused intravenously for 10 min, with 2% lidocaine for airway surface anesthesia, and a 3% ephedrine cotton swab was used to contract the nasal mucosa vessels. Before tracheal intubation, fentanyl (1 μg/kg) and midazolam (0.02 mg/kg) were administered intravenously. Awake fiberoptic nasotracheal intubation was performed in the semi-reclining position. Intravenous anesthesia was administered immediately after successful intubation, and a BB was inserted laterally. The pre-intubation preparation time, intubation time, facial grimace score, airway responsiveness score during the fiberoptic introduction, time of end tracheal catheter entry into the nostril, and lung collapse and surgical field score were measured. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were recorded while entering the operation room (T1), before intubation (T2), immediately after intubation (T3), 2 min after intubation (T4), and 10 min after intubation (T5). After surgery, all patients were followed for adverse reactions such as epistaxis, sore throat, hoarseness, and dysphagia.
RESULTS: All patients had a history of AS (20.4 ± 9.6 years). They had a Willson\'s score of 5 or above, grade III or IV Mallampati tests, an inter-incisor distance of 2.9 ± 0.3 cm, and a thyromental (T-M) distance of 4.8 ± 0.7 cm. The average pre-intubation preparation time was 20.4 ± 3.4 min, intubation time was 2.6 ± 0.4 min, facial grimace score was 1.7 ± 0.7, airway responsiveness score was 1.1 ± 0.7, and pulmonary collapse and surgical exposure score was 1.2 ± 0.4. The SBP, DBP, and HR at T5 were significantly lower than those at T1-T4 (P < 0.05). While the values at T1 were not significantly different from those at T2-T4 (P > 0.05), they were significantly different from those at T5 (P < 0.05). Seven patients had minor epistaxis during endotracheal intubation, two were followed 24 h after surgery with a mild sore throat, and two had hoarseness without dysphagia.
CONCLUSIONS: Patients with AS combined with severe cervical and thoracic kyphosis should be intubated using fiberoptic bronchoscopy under conscious sedation and topical anesthesia. Proper doses of penehyclidine hydrochloride, dexmedetomidine, fentanyl, and midazolam, combined with 2% lidocaine, administered prior to intubation, can provide satisfactory conditions for tracheal intubation while maintaining the comfort and safety of patients. BBs are safe and effective for one-lung ventilation in such patients during thoracotomy.