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A 14-year-old girl is scheduled to have an excision of a mandibular mass in a hospital in Kigali, Rwanda. She is otherwise healthy, takes no medications, and has no allergies. She weighs about 42 kg and is 144 cm tall (BMI 20.3). On examination, she appears to be nervous, but cooperative. She has a large right mandibular mass restricting her mouth opening (3 cm) (Figures 7–1 and 7–2). She has a Mallampati IV score and jaw protrusion is limited, but, the range of motion of her cervical spine is normal. She agrees to have an awake intubation with some reluctance. Routine monitors (noninvasive blood pressure monitor, ECG, and pulse oximeter) are placed on her upon arrival at the operating room (OR). Intravenous (IV) access is established and a judicious amount of IV ketamine (bolus of 10 mg) is administered for sedation. Topical anesthesia is achieved with lidocaine sprays alone. Since a flexible bronchoscope is unavailable, the following plans are prepared to secure her airway and communicated to everyone involved in her care. Plan A: blind nasal intubation using a BAAM (Beck Airway Airflow Monitor) whistle1; Plan B: orotracheal intubation using a video-laryngoscope (C-MAC); and Plan C: a surgical airway. Unfortunately, blind nasal intubation is not successful after a number of attempts as the endotracheal tube (ETT) repeatedly enters the esophagus. Tracheal intubation using the C-MAC is also difficult with poor visualization of the glottis, particularly when the posterior aspect of the tongue begins to bleed. With ongoing suction around the bleeding site, an attempt with direct laryngoscopic intubation also fails. It becomes obvious that the appropriate course of action is for the otolaryngologist to perform an awake tracheotomy under ketamine sedation and local anesthesia. With oxygen supplementation through a face mask (8 L·min−1) and repeated boluses of IV ketamine (10 mg), tracheotomy is secured while oxygen saturation remains above 90% during the procedure. Anesthesia is induced with thiopental and anesthesia is maintained with 1 to 1.5 MAC of halothane. The otolaryngologist excises the mandibular mass and the patient is transferred to the intensive care unit in stable condition at the conclusion of the surgical procedure with ventilation maintained through the tracheostomy tube.


Lateral view of a 14-year-old patient with a large right mandibular mass.


Front view of a 14-year-old patient with a large right mandibular mass restricting her mouth opening.


The fundamental goals of airway management are the maintenance of adequate ventilation, oxygenation, and protection from aspiration. In the majority of clinical settings, these three goals are achieved in tandem, usually via orotracheal intubation using a conventional direct laryngoscope. As the location, time of day, skill set of the practitioner, and the devices available (i.e., ...

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