Navigating the Dual Challenge of Difficult Airway and Low Cardiac Reserve in Oral Cancer Surgery: A Case Series

Oral cancers, particularly Squamous Cell Carcinomas (SCCs), cause fibrosis and structural changes within the oral cavity, creating complex airway management challenges. These cases often present anaesthetic difficulties, including restricted access for instrumentation, distorted anatomy that increases the difficulty of ventilation and intubation, and a heightened risk of bleeding or airway obstruction. Postoperative concerns, such as airway oedema, respiratory compromise, and pain management, further complicate the perioperative period. This case series explores the anaesthetic management of three patients with oral cancer and significant cardiovascular comorbidities. Two key factors that created anaesthetic challenges were restricted mouth opening of less than 2 cm (less than two finger breadths) and compromised cardiac function, which carries risks of haemodynamic instability and arrhythmias. Awake Fiberoptic Intubation (AFO) was chosen to secure the airway and avoid a situation where ventilation or intubation would be impossible. The nasal cavities were instilled with xylometazoline drops. Additionally, a transtracheal block was performed in the sitting position, using 4 mL of 4% topical lignocaine to anaesthetise the trachea, significantly reducing the cough reflex and discomfort during intubation. Sedation was provided with midazolam and fentanyl after the administration of supplementary oxygen. Fiberoptic intubation was carried out, and the airway was secured by railroading a flexometallic tube over the bronchoscope. Induction was performed with midazolam (0.04 mg/kg), fentanyl (2 mcg/kg), and vecuronium (0.1 mg/kg). Anaesthesia was maintained using sevoflurane, nitrous oxide, and oxygen. Haemodynamic monitoring was conducted with Central Venous Pressure (CVP) and Arterial Blood Pressure (ABP) measurements. The surgical procedure went uneventfully. After surgery, the patients were kept on a T-piece in the Post-Anesthesia Care Unit (PACU) and were closely monitored for airway patency, respiratory effort, and haemodynamic stability. This case series emphasises anesthetic strategies that manage complex airway and cardiovascular issues in high-risk oral cancer surgery while addressing critical postoperative considerations.