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Recent developments in regional anesthesia have resulted in a number of innovative and refined options to practitioners, often allowing regional techniques to be used for patients with presumed difficult airways. However, not every surgery can be performed under regional anesthesia. In addition, even in the hands of the most skilled regional anesthesiologist, blocks are subject to a certain rate of complications or failure.1–4 In addition, there are many situations in which the anesthesiologist is called on to secure an airway in less than ideal circumstances. Expertise with regional anesthesia of the airway allows intubation in awake patients with suspected difficult intubation, upper airway trauma, or cervical spine fractures. Therefore, it is essential that every regional anesthesiologist be skilled in the administration of general anesthesia and especially in the management of the difficult airway.

In recent years, there have been many advances in difficult airway management. The introduction of the laryngeal mask airway, and later the intubating laryngeal mask airway have changed the American Society of Anesthesiologists' difficult airway algorithm significantly.5 Despite new devices and techniques being added to the arsenal daily, the mainstay of difficult airway management remains flexible fiberoptic laryngobronchoscopic intubation. Fiberoptic intubation can be performed under a variety of conditions. However, one major decision must be made with every procedure: Will the patient be intubated while under general anesthesia, or does the patient need to be awake during intubation?6 Intubation under general anesthesia (even with inhalational induction and spontaneous respiration) carries the inherent risk of losing control of the difficult airway. For this reason, many anesthesiologists, on recognition of a difficult airway, elect to perform an awake intubation using either fiberoptic laryngobronchoscopy or awake direct laryngoscopy.

Direct laryngoscopy in an awake, unprepared patient can be extremely challenging. Excessive salivation and gag and cough reflexes can make intubation difficult, if not impossible, under awake conditions. In addition, the stress and discomfort may lead to undesirable elevations in the patient's sympathetic and parasympathetic outflow. Several highly effective topical and regional anesthesia techniques have been developed to subdue these reflexes and facilitate intubation. Each of these techniques has the common goal of reducing sensation over the specific regions that will be encountered by the fiberoptic bronchoscope and endotracheal tube.

Relevant Anatomy

To decide on a proper approach to an awake fiberoptic intubation, one must determine what structures need to be anesthetized along the two basic routes of intubation (oral or nasal) to facilitate optimal surgical conditions in the context of patient-specific anatomic considerations. Each of these routes has a well-defined pattern of innervation that can be specifically blocked to provide adequate anesthesia.

The nasal cavity is innervated by the greater and lesser palatine nerves and the anterior ethmoidal nerve. The palatine nerves arise from the trigeminal nerve via the pterygopalatine ganglion and innervate the nasal turbinates and most of the nasal septum. The pterygopalatine ganglion is located posterior ...

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