Challenging Airway Management When Intubation after Induction is Seemingly Impossible

To the Editor, Postburn contractures involving the neck and face present challenges in both reconstructive surgery and anaesthetic management.[1] Severe scarring and contracture of the neck can lead to fixed flexion deformities, impaired neck extension and restricted mandibular movement, all of which complicate airway alignment and access. When combined with pan-facial burns, the challenge becomes greater due to distortion of facial landmarks, limited mouth opening, nasal stenosis and perioral contractures, which make mask ventilation, supraglottic device placement and both oral and nasal intubation extremely difficult.[2] Awake fibreoptic bronchoscopy is considered the gold standard in anticipated difficult airways, but its success relies mainly on adequate topical anaesthesia of the airway, patient cooperation and operator skill. This case highlights a complex presentation of postburn neck contracture with pan-facial involvement, where preparing for awake intubation and securing the airway posed significant challenges. Written informed consent for publication was obtained from the patient. A 24-year-old female with a history of burn injuries to her face, neck, right upper chest and right upper arm 6 months ago was scheduled for postburn neck contracture release, right upper eyelid ectropion correction and skin grafting with perifascial areolar tissue [Figure 1]. She had complaints of a diminishing vision in her left eye and an inability to straighten her neck. On examination, there was a postburn scar present on the forehead and bilateral temporal regions, accompanied by a complete loss of bilateral eyebrows and eyelids [Figure 1a]. Airway examination revealed that the mouth opening was 0.5 cm (microstomia), postburn contracture of the neck leading to fixed flexion deformity, mentosternal and bilateral mandibular–clavicular contracture bands [Figure 1b]. Postburn scar involving the dorsum of the nose with complete loss of the external osseocartilaginous framework of the nose. The thyroid cartilage, thyroid membrane and cricoid cartilage were not distinctly appreciable. All laboratory tests were found to be within normal ranges.Figure 1: Pan-facial burn contracture with airway distortion. (a) Front view, (b) Side viewAwake fibreoptic nasal intubation was the plan for securing the airway [Figure 1a], while awake contracture release under local anaesthesia, followed by tracheostomy, was kept as a back-up plan [Figure 1b]. On the day of surgery, the patient was prepared for awake fibreoptic intubation with an injection of glycopyrrolate 0.2 mg I.M. 30 min before the procedure and received 4 ml of 4% lignocaine nebulization twice at 15-min intervals in the preoperative area after securing an intravenous cannula.[3] Inside the operating room, the patient was made to lie supine, and standard monitors were attached. Nasal airway preparation was done by administering xylometazoline drops and 10% lignocaine spray to both nostrils. This was followed by serial dilatation with nasopharyngeal airway size 5, 5.5 and 6, along with 2% lignocaine gel.[4] In this case, airway blocks were avoided due to the distorted anatomy of the neck. Awake nasal fibreoptic (scope size of 4.3 mm) intubation was attempted, and the trachea was intubated on the third attempt with a tube size of 5 mm. The spray as you go technique was applied using 4% lignocaine of volume 2 ml during intubation. In our case, there was difficulty in awake intubation, as along with postburn neck contracture, there was limited mouth opening and destruction of the nasal framework, which makes oral and nasal awake fibreoptic intubation difficult. The use of an intubating laryngeal mask airway and a laryngeal mask airway was not feasible due to markedly restricted mouth opening, which prevented proper device insertion. The procedure was challenging due to insufficient local anaesthesia of the airway, an intact cough reflex, patient non-compliance and difficulty advancing the scope. Mishra et al.,[5] in a case report of postburn neck contracture and microstomia, along with a constricting band across the neck, resulted in a fixed flexion deformity at the atlanto-occipital joint, eliminating the ability to extend the neck. After three failed intubation attempts, an emergency release of the labial commissures was performed under local anaesthesia using 2% lidocaine with adrenaline. Following the procedure, the mouth opening was reassessed, and an I-gel size 3 was placed to complete the whole procedure. In patients with pan-fascial-burn injuries, it may be necessary to preserve spontaneous ventilation throughout the procedure and avoid the use of muscle relaxants. The anaesthesiologist should be prepared with a comprehensive, multitiered strategy for airway management. It is effective ventilation, rather than the intubation itself, that is critical for saving a patient’s life.[2] Consent statement Written informed consent was obtained from the patient for the publication of this case report and accompanying image. Author Contributions A.K.: This author helped in Conceptualization, Writing-original draft. K.S.: This author helped in Writing-review & editing. R.I.N.: This author helped in Writing-review & editing, Data curation. N.M.N.: This author helped in Writing-review & editing, Data curation. Disclosure of use of artificial intelligence (AI) assistive or generative tools The author(s) confirm that no AI-assisted technologies was used in the conception, data collection, analysis, or drafting of this manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.