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Airway·CA-2

Difficult Airway: Supraglottic Mass

A 68 y.o. patient with a large supraglottic mass and limited neck extension. Test your awake fiberoptic vs. tracheostomy decision logic.

The stem

A 68 y.o. male with a history of heavy smoking and alcohol use presents for biopsy of a large supraglottic mass. He has noticed increasing hoarseness and difficulty swallowing solids. On exam, he has a Mallampati III airway and limited neck extension. During pre-oxygenation, he becomes increasingly anxious and stridorous...

Focus

Management of upper airway obstruction, decision-making for awake fiberoptic vs. tracheostomy.

Examination relevance

Defending your choice to NOT induce general anesthesia in a tenuous airway is a common test of 'the consultant mindset'.

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Expert sample response

I will manage this patient as a suspected difficult airway. In a patient with a large supraglottic mass and active stridor, my first priority is avoiding any intervention that could cause total airway occlusion—specifically, a standard Rapid Sequence Induction (RSI) or deep sedation.

I will proceed with an awake fiberoptic intubation (Awake Fiberoptic Intubation (AFOI)). I will explain the procedure clearly to the patient to ensure cooperation, and I will topicalize the airway using 4% lidocaine (nebulized and targeted sprays) while maintaining a sitting position to assist ventilation. I will have a surgeon scrubbed and a tracheostomy kit at the bedside before starting. If the Awake Fiberoptic Intubation (AFOI) fails or the patient loses the ability to ventilate, we will proceed immediately to a surgical airway under local anesthesia. Inducing general anesthesia before securing this airway is unsafe and would be a board failure.

Full walkthrough

What the Examiner Is Testing

This case tests whether you understand when NOT to induce. The core principle is simple: a patient with active stridor and a fixed upper airway obstruction cannot tolerate the loss of muscle tone that comes with RSI or deep sedation. Your job is to defend that position clearly.

The Board Trap

The trap is doing a standard RSI because the patient is anxious and the surgeon is impatient. Attempting to push propofol and succinylcholine into a stridorous airway with a supraglottic mass is a board failure. You cannot mask-ventilate through a mass that is already causing obstruction — and once you induce, you own the airway completely.

Walk-Through: How This Case Plays Out

Examiner: Your patient is becoming increasingly anxious and stridorous during pre-oxygenation. The surgeon is pushing to get started. How do you proceed?

Me: I would not induce general anesthesia. This is an awake fiberoptic intubation. The patient has a large supraglottic mass and active stridor — if I give propofol or midazolam, I risk losing what little airway he has left. I'm going to topicalize with nebulized 4% lidocaine, position him sitting upright, and pass the scope while he's breathing on his own. I want a surgeon scrubbed and a tracheostomy kit open on the field before I start anything.

Examiner: The patient is not cooperative. He keeps moving and won't hold still for topicalization. What do you do?

Me: I would use very careful, titrated dexmedetomidine — it provides sedation and analgesia without killing respiratory drive. Small incremental doses, watching his respiratory pattern the entire time. If he loses his respiratory drive, I'm in trouble, so I stay conservative. I'm also going to have him stay seated — that position helps him breathe. I would not reach for propofol.

Examiner: The fiberoptic scope is in, but you can see the mass is nearly obstructing the glottis. You can barely visualize the cords. What now?

Me: I would advance the scope past the mass using the small residual lumen, railroad the ETT over it — I'd use a 6.0 cuffed tube since the anatomy is distorted. If I cannot pass the tube at all, I would withdraw and go directly to the surgeon for an awake tracheostomy under local anesthesia. I will not attempt blind RSI at this point. The fallback is a surgical airway, not another attempt at crashing the airway.

Examiner: After intubation, the patient becomes hypotensive. What do you do?

Me: I would push phenylephrine boluses to maintain the MAP. He's likely been running on high sympathetic tone from the stridor and anxiety — once the airway is secured and he relaxes, the SVR can drop. I'd have phenylephrine already drawn up for exactly this reason. If the hypotension persists, I'd reassess volume status and consider norepinephrine.

Key Phrases That Score Points

  • "I would not induce general anesthesia in this patient — active stridor is a contraindication to RSI."
  • "I want the surgeon scrubbed and a tracheostomy kit open before I touch this airway."
  • "Dexmedetomidine is my sedation of choice here because it preserves respiratory drive."
  • "If AFOI fails, we go directly to a surgical airway under local — there is no second RSI attempt."
  • "Sitting position throughout — it helps him breathe and reduces the work I'm asking him to do."

Why This Case Appears on the Boards

Defending the decision to NOT induce is a core test of the consultant mindset. Any resident can push propofol. The consultant thinks three steps ahead — what happens when the airway collapses — and builds a plan around that failure mode before touching the patient.