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.
"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..."
Management of upper airway obstruction, decision-making for awake fiberoptic vs. tracheostomy.
Defending your choice to NOT induce general anesthesia in a tenuous airway is a common test of 'the consultant mindset'.
How a Board-Certified Consultant answers this scenario.
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.