ISPUB.COM The Internet Journal of Anesthesiology Volume 19 Number 1 1 of 4 Awake fiberoptic intubation after several failed intubation attempts: A case report M Daabiss, N ElSayed Citation M Daabiss, N ElSayed. Awake fiberoptic intubation after several failed intubation attempts: A case report. The Internet Journal of Anesthesiology. 2008 Volume 19 Number 1. Abstract Airway management demands much more than mere technical proficiency with traditional methods of intubation. The anesthesiologists must be highly skilled in assessing the adequacy of the airway and must be familiar with the implications of various forms of airway pathology. Difficulties in intubation have been associated with serious complications, particularly when failed intubation has occurred (1). We describe a successful fiberoptic-guided tracheal intubation following several attempts of failed intubation in a post burn patient with tissue expander. INTRODUCTION Tissue expanders are used by plastic surgeons for scar revision, Tissue expander devices are usually made of 100% medical grade silicone( 2 ). It includes a silicone expansion bag of varying volumes, a self-sealing injection port and a connecting tube. The expander is filled with as much saline as will comfortably allow wound closure( 3 ). The tissue expanders in the neck usually interfere with the airway and many reported failed intubation in such patients. We report a case with neck tissue expander obscuring the airway. CASE REPORT A 43 year old Saudi male patient of 70 kilogram and 165 cm height, with post burn scars on face, neck and upper chest wall since age of 4ys presented for reconstruction of facial lesions. He had a short thyromental distance (less than 7 cm), short sternomental distance, limited neck movement, interincisor distance less than 3 cm, large tongue, burned narrow nostrils and a big tissue expander (filled with 400ml of silicone) at the left side of neck (Fig.1). His previous anesthesia report documented: grade IV laryngoscopic view as described by Cormack and Lehane( 4 ), difficult to maintain face mask and several failed attempts to intubate while the successful attempt was hardly done over bougie. The patient was scheduled for facial reconstruction, the anesthetist planed to intubate him using fiberoptic laryngoscopy through the nasal route under general inhalational anesthesia while patient is spontaneously breathing but he reported difficult to visualize the vocal cords and failed to intubate after several attempts which were complicated with nasal bleeding and the procedure was aborted and the surgery was postponed. Figure 1 Figure 1: A Tissue expander at the left side of neck One week later, we were assigned to anaesthetize this patient for the same surgical procedure, we planned to intubate him orally awake using fiberoptic laryngoscopy and to discuss with surgeons about deflating the tissue expander before intubation. Preanesthetic assessment and psychological preparation of the patient for the awake intubation along with explanation of all steps of that procedure were performed. After getting the patient's written consent for the surgery and anesthesia, neck x-ray (anterior, lateral views) was done which revealed right shift of the trachea (by left neck tissue expander). Intravenous injection (IV) of 4 mg ondansetron, 0.2 mg glycopyrolate and 50 mg ranitidine were given as well as 30 ml of sodium citrate orally and the tissue expander was deflated by plastic surgeon 30 minutes preoperative. The