Unforeseen Airway Obstruction in Orthognathic Surgery: When Nasal Intubation Fails

Orthognathic surgery is an elective procedure. Yet unexpected challenges, such as difficult intubation, can arise perioperatively. This report presents two cases of failed nasal intubation requiring alternative approaches to avoid canceling surgery. The first case involved a 57-year-old male with obstructive sleep apnea and dentoskeletal deformity undergoing bimaxillary advancement. Despite multiple attempts, nasal intubation failed, prompting submental diversion, which allowed successful surgery. The second case involved a 15-year-old female with a history of cleft-related surgeries and suspected Goldenhar syndrome. After failed intubation with a size 6.0 tube, submental diversion was again employed, enabling a seven-hour procedure without complications. These cases highlight the importance of preoperative airway assessment, particularly in patients with obstructive sleep apnea or prior maxillofacial surgery. While nasopharyngoscopy is not routine, it may be beneficial in high-risk cases. Submental intubation offers a viable alternative, ensuring surgical access while avoiding cancellation. Informed consent should address potential intubation difficulties to mitigate legal risks.