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A 57-year-old male was admitted for laparoscopic appendectomy for acute appendicitis. He was otherwise healthy, apart from essential hypertension, for which he took hydrochlorothiazide. He had fasted for more than 12 hours.

On examination, he was lying in a stretcher in a moderate amount of pain. He was hemodynamically stable. His height was 183 cm and his weight was 80 kg with a body mass index (BMI) 23.9 kg·m−2. His airway examination demonstrated a Mallampati score of II, mouth opening of 4.5 cm, thyromental distance of 6 cm, and good jaw protrusion. He had a full set of teeth, was not obese, and was estimated to be easy to ventilate. His cardiac and respiratory examinations were normal.

The patient was premedicated with intravenous midazolam 1 mg, fentanyl 200 mcg, and this was followed by denitrogenation with 100% oxygen by facemask. As he didn’t have any indicators of a difficult airway, a decision was made to induce anesthesia with propofol 200 mg and rocuronium 50 mg. Bag-mask-ventilation (BMV) was established with an oral airway. Initial evaluation with direct laryngoscopy (DL) using a Macintosh laryngoscope showed a Cormack-Lehane (C/L) Grade 3 view. The first attempt with DL and an Eschmann Tracheal Introducer (ETI) resulted in an esophageal intubation. BMV was reestablished and a Glidescope® was prepared. When the Glidescope® was inserted, only the posterior arytenoids could be visualized, and two attempts with a styleted endotracheal tube (ETT) and a Tracheal Introducer were unsuccessful (and were associated with a small amount of bleeding in the oropharynx).

At this point, the decision was made to attempt flexible bronchoscopy. Unfortunately, BMV became more difficult, the patient's oxygen saturation dropped into the low 80's, and it became necessary to insert nasal and oral pharyngeal airways and begin a two-hand and two-person BMV technique. A #4 Laryngeal Mask Airway Classic® (LMA Classic®) was rapidly prepared and inserted without complication, at which point it became possible to easily ventilate the patient. Sevoflurane was selected to maintain anesthesia, and to manage escalating tachycardia and hypertension. A pediatric bronchoscope with an ensleeved Aintree Intubation Catheter (AIC, Cook Medical Inc., Bloomington, IN) was then inserted through the LMA into the trachea. Both the bronchoscope and the LMA were then removed leaving the AIC in the trachea. An ETT was advanced into the trachea over the AIC. Correct tracheal placement was confirmed by auscultation and capnograph recording.

The surgery was uneventful and the patient emerged from anesthesia fully awake, warm, with adequate analgesia, and with no residual neuromuscular blockade. The difficult airway cart was brought to the room. Tracheal extubation was uneventful, although he did complain of a sore throat in the post-anesthetic care unit, which gradually improved. He was later informed of the difficulty and provided with a notice to inform any subsequent practitioner of his difficult airway.

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