A Three-dimensional Difficult Airway: A Case of Anatomy, Bleeding and Time Constraints

Anticipated difficult airways often have superimposed unanticipated difficulties. In life-saving and limb-saving emergency surgeries, anaesthesiologists are often required to take up patients who are under-evaluated and unoptimised. We report a case of a 62-year-old patient with a prior history of malignancy of the nasopharynx presenting with acute paraparesis for emergency spinal decompression. His airway management posed a threefold difficulty. He had a preexisting difficult airway with severely limited mouth opening and restricted neck extension due to previous surgery and radiotherapy. Further, his airway management got overtly complicated due to a sudden, torrential upper airway bleeding. Finally, the emergency nature of the surgery influenced judgements and made it non-amenable to postponement. Awake fibreoptic intubation was the initial choice for the technique of intubation; however, it had to be modified to secure the airway successfully. A second suction, an awake patient and front-of-neck access preparedness proved invaluable in the management of this airway crisis. Non-availability of preoperative airway imaging was the direct contributory factor for this critical airway situation. Decision-making during emergencies is influenced by several factors and can be overwhelming. Hence, we propose a checklist to preempt, prepare and perform in such compound difficult airways to improve patient outcomes.