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A 14-year-old female 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 kg·m–2). 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 upon her arrival in 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. 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: awake blind nasal intubation using a BAAM (Beck Airway Airflow Monitor) whistle1; Plan B: orotracheal intubation using the only available video-laryngoscope (C-MAC Macintosh blade); 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 due to inadequate upper airway anesthesia. 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 otorhinolaryngologist to perform an awake tracheotomy under ketamine sedation and local anesthesia. With oxygen supplementation through a facemask (8 L∙min–1) and repeated boluses of IV ketamine (10 mg per dose), tracheotomy is secured. Oxygen saturation remains above 90% during the procedure. Anesthesia is then induced with thiopental and is maintained with 1 to 1.5 MAC of halothane. The otorhinolaryngologist excises the mandibular mass, and the patient is transferred to the intensive care unit (ICU) in stable condition at the conclusion of the surgical procedure. Ventilation is 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 during orotracheal intubation under direct laryngoscopy. As the location, time of ...

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