Direct laryngoscopy was expected to be difficult or impossible. If the initial awake, sedated fiberoptic intubation approach failed, the alternative plan was for inhaled anesthetic induction followed by intubation attempts maintaining spontaneous ventilation with personnel and equipment at hand for an emergent invasive approach to the airway.A flexible bronchoscope, threaded through a nasotracheal tube, was inserted into the naris prepared with oxymetazoline and advanced into the pharynx (see Supplemental Digital Content 1, which is an edited video of the procedure for securing the airway of the patient described with flexible endoscopic intubation under sedation and topical anesthesia, http://links.lww.com/ALN/A572). The narrowed oropharynx was observed to intermittendy collapse during respiration and completely obstruct any view of the supraglottic larynx. Excessive anterior soft tissue presented a narrow lumen for endoscopic navigation. Bubbles seen with respiration guided navigation beneath a barely recognizable epiglottis, revealing an excellent view of the glottic inlet followed by uneventful tracheal intubation and induction of general anesthesia.
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