The exposed glottis paradox: Spontaneous ventilation-assisted trans-wound intubation in complete translaryngeal transection

Dear Editor, Penetrating cut-throat injuries are among the most lethal airway emergencies encountered in trauma care.[1] While laryngeal trauma is well described, complete translaryngeal transection with externalisation of the glottic inlet is exceptionally rare and creates a dangerous illusion of airway control. This injury exemplifies the exposed glottis paradox. Despite perfect visualisation of the vocal cords, the upper airway is physiologically non-functional because anatomical continuity between the upper and lower airways is lost. Conventional airway algorithms therefore fall short, and management must be driven by physiology rather than visualisation.[2] We encountered a man in his fifties, approximately 70 kg with a suicidal cut-throat injury presenting with a wide open-book neck wound and complete laryngeal transection, with the glottis fully externalised and visibly bubbling with spontaneous respiration [Figure 1]. The patient was conscious, tachypnoeic, and hypoxaemic. Mask ventilation and conventional pre-oxygenation were ineffective due to a massive air leak through the wound. Oxygenation was therefore achieved by directing high-flow oxygen (15 L·min-¹) using a sterile 10-French suction catheter connected to an oxygen source placed 2–3 cm into the distal airway lumen via the wound while allowing uninterrupted spontaneous ventilation. The airway was secured using spontaneous-ventilation-assisted trans-wound intubation (SVATI), a spontaneous-ventilation–preserving trans-wound intubation approach consistent with previously reported airway management strategies in complete laryngotracheal disruption followed by definitive tracheostomy [Figure 2].[3]Figure 1: Complete translaryngeal exposure of the glottic inletFigure 2: Trans-wound endotracheal intubation followed by formal tracheostomyComplete translaryngeal transection converts the respiratory system from a closed-circuit airway into an open-circuit airway, where atmospheric air preferentially escapes through the neck wound instead of reaching the alveoli. In this setting, face-mask pre-oxygenation is physiologically futile regardless of technique or seal. Direct para-oxygenation of the distal airway lumen should therefore be considered the first-line strategy to prolong safe apnoea time when top-down oxygen delivery is impossible. Flooding the wound with high-flow oxygen creates a localised oxygen reservoir at the site of gas exchange and mitigates rapid desaturation during airway manipulation. This situation also creates a visualisation–navigation paradox. The glottis is clearly visible through the neck wound, yet oral intubation risks false passage formation, worsening the transection, or loss of the airway. Loss of spontaneous ventilation in this already disconnected system risks sudden airway collapse and a cannot-ventilate scenario. SVATI addresses this by prioritising preservation of intrinsic respiration. Dissociative sedation was achieved using titrated intravenous ketamine (0.5 mg·kg-¹), preserving spontaneous respiration and airway tone, functioning as a physiological bridge rather than merely an induction agent. Emergency tracheostomy is frequently advocated in cut-throat injuries[4]; however, in the presence of active bleeding, distorted anatomy, obesity, and caudal retraction of the distal trachea, it may be hazardous and time-consuming in the acute phase. SVATI offers a pragmatic alternative when complete anatomical discontinuity exists.[3] In partial transections, trans-wound intubation is dangerous as the endotracheal tube may propagate the tear. In complete transection, however, SVATI functions as a rapid stent-and-seal manoeuvre, restoring airway alignment, re-establishing a functionally closed ventilatory system, and limiting the aspiration of blood and secretions. A frequently underappreciated challenge following SVATI is tube stability. With no intact skin or laryngeal framework, the endotracheal tube cannot be conventionally secured and is inherently unstable. Continuous manual stabilisation by a dedicated assistant can act as a critical manual anchor and should be regarded as an integral component of the technique rather than an optional precaution. Loss of this anchor before definitive airway fixation may result in catastrophic airway loss. The transition from a trans-wound endotracheal tube to a formal tracheostomy represents the highest-risk phase of airway management. Caudal retraction of the distal free end of the trachea into the mediastinum alters airway alignment and increases the risk of false passage formation and failed tube placement during emergency tracheostomy. Standard guides such as bougies or suction catheters may be insufficient. Applying cephalad traction using Allis or Babcock forceps on residual laryngeal or thyroid cartilage remnants physically elevates the distal airway into the surgical field, realigns the airway axis, and converts a technically demanding tracheostomy into a controlled and reproducible procedure. Penetrating neck trauma is not the domain of a single speciality but a shared mission.[2–5] The anaesthesiologist restores physiology through techniques such as SVATI, while the surgeon provides definitive anatomical fixation. Recognition of the exposed glottis paradox and adoption of physiology-driven airway strategies may prevent catastrophic airway loss in this rare but devastating injury. Study data availability Not applicable. Disclosure of use of artificial intelligence (AI)-assistive or generative tools Artificial intelligence (AI) tools have not been utilized in the manuscript, except that software has been used for grammar corrections and references. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient consented to the images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.