Awake Fiberoptic-Guided Nasotracheal Intubation for Anticipated Difficult Airway Management in a Patient With Advanced Oral Tongue Carcinoma: A Case Report

Large oral tongue tumours can complicate airway management through anatomical distortion, restricted intraoral working space, excessive secretions, and the risk of bleeding.Preserved mouth opening and cervical spine mobility may therefore underestimate the difficulty of airway instrumentation.We report the anaesthetic management of a 67-year-old man with a large left oral tongue lesion associated with progressive dysphagia, odynophagia, excessive salivation, and impaired speech.Airway examination demonstrated marked tongue displacement and a modified Mallampati grade IV airway despite adequate mouth opening and preserved cervical spine mobility.Awake fiberoptic-guided nasotracheal intubation was selected to secure the airway before induction of general anaesthesia while maintaining spontaneous ventilation.Preparation included topical oxymetazoline, intravenous glycopyrrolate, nebulised lidocaine, additional local airway anaesthesia, and spray-as-you-go topicalisation.The cumulative administered lidocaine dose was 160 mg.Intravenous midazolam 1 mg was administered for anxiolysis.A 6.5-mm cuffed endotracheal tube was placed through the right nostril on the first attempt, with bronchoscopic visualisation and continuous waveform capnography confirming tracheal placement.No immediate intubation-related complication was reported.The patient underwent tongue lesion excision, left modified radical neck dissection, and percutaneous endoscopic gastrostomy tube insertion.Histopathology confirmed well-differentiated squamous cell carcinoma.He was extubated while fully awake, observed in the postanaesthesia care unit, and discharged on postoperative day four.This case illustrates anatomy-based selection of an established awake intubation technique when tumour-related distortion is not fully reflected by conventional airway measures.It does not establish comparative superiority or validate a particular topicalisation regimen.